Need some fast help. (Nursing Dx)

when you are planning care you are problem solving. follow the steps of the nursing process and it will keep you focused:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   • a physical assessment of the patient
     
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
     
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
     
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)

• it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.
  • your instructors might have given it to you.
    
  • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
    
  • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
    
  • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
    
  • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
    • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
      
    • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm

[*]planning (write measurable goals/outcomes and nursing interventions)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

medical diagnosis is cholecystitis and he needs to have a laparoscopic cholecystectomy but it has been delayed because the night before surgery his heart rate dropped to 30 beats [note: they will address this bradycardia first because it is life-threatening (probably sick sinus syndrome) before they proceed with the surgery.] a sustained heart rate of 30 beats per minute is an electrical dysrhythmia. (this very thing happened to me a year ago and i now have a pacemaker.) based on the information you posted, the patient has the following symptoms:

• epigastric pain 5/10
  
• bradycardia of 30 beats at night at rest
  
• bmi shows him as overweight
  
• i saw him outside smoking
  
• questioning members of health care team about his heart problem

if you look up information about cholecystitis and gallstones you will find that they cause epigastric pain because of the smooth muscle spasm that the stones cause to the hepatic and common bile ducts depending on where the stones happen to be rattling around. muscle spasms are extremely painful. ask any runner who happens to get one in their leg. in addition, inflammation, the "-itis" part of this cholecystitis, produces heat, redness, swelling and pain, the 4 cardinal signs of inflammation in that order. when you get to the stage of swelling, and the inflammation is internal, surrounding structures get pushed upon including nerve pain receptors. pain results. and that is the source of the patient's epigastric pain. but i do not want you to take my word for this. you need to read the pathophysiology of cholecystitis for yourself.

this patient's heart problem is probably a malfunction of the electrical system of his heart. after a cardiology consult he will likely be having a pacemaker inserted. his laparoscopic cholecystectomy will be delayed until then.

so, i would diagnose this patient with

1. decreased cardiac output r/t altered heart rate aeb bradycardia of 30 beats at night at rest
   • [color=#3366ff]decreased cardiac output
     
   • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=09

[*]imbalanced nutrition: more than body requirements r/t excess calorie intake in relation to metabolic need aeb high bmi for height and weight

• [color=#3366ff]imbalanced nutrition: more than body requirements
  
• http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=38

[*]acute pain r/t inflammation of gallbladder aeb epigastric pain 5/10

• [color=#3366ff]acute pain
  
• http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=40

[*]ineffective health maintenance r/t unwillingness make appropriate changes aeb continued smoking behavior ands refusal to adapt to hospital telemetry protocols

• [color=#3366ff]ineffective health maintenance
  
• http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=27

[*]deficient knowledge of heart condition and its treatment r/t unawareness of subject aeb questions and statements made to members of health care team seeking information about new onset of bradycardia and how it will be treated

• [color=#3366ff]deficient knowledge (specify)
  
• http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm?plan=34

but here's where i get stuck. i was thinking he also has "decreased cardiac output r/t htn and bradycardia" however, i don't have the observeable signs and symptoms because the patient had warm extremities and had no observable problems breathing. he was in sinus bradycardia, so other than the fact that his heart was pumping slowly, there was no electrical dysrhythmia.

i was going to use "ineffective health maintenance r/t lack of knowledge aeb failure to respond to important symptoms reflective of health state." but the problem is that this diagnosis relates to his cholecystitis. in my paper i have a written assessment and include that the patient didn't seek health care for a year after the onset of symptoms. i worry that my instructor is going to think i'm tying this to his heart conditions, but the patient was asymptomatic for those and thus could not respond. . .since he left the floor even though i told him we couldn't monitor him off the floor, i was going to use "noncompliance r/t patient's value system aeb refusal to stay on the unit in order to monitor his heart via holter." still, i think there's a problem with this because i typically only use the noncompliance diagnosis with regards to medications. does it fit?

hope this has answered some of your questions.

The patient is monitored in the OR continuously by the anesthesiologist who can give him IV atropine if his heart goes brady or they can even insert a temporary pacemaker if things get bad enough. The man is definitely in for a cardiac workup in the future. He needs to lose the cigarettes, but they have most likely already done their damage to his circulatory system not to mention putting him at risk for CA of the lung.

Do you have this patient postoperatively?

A year ago when I was hospitalized for a septic wound infection after a colon resection the aides found I had a heart rate of 48 during a set of vital signs one morning. I was put on telemetry. I had no clue this low heart rate was happening. That night my heart rate went down to 38 and nurses were standing over my bed waking me up asking me if I felt OK. Sure, what's wrong I asked, and was told my heart rate was 38. Hmmm. Cardiologist was in the next day. Because I was septic I had to wait a week for the antibiotics to, hopefully, do their job, before a pacemaker could be inserted. During that week my heart rate almost continually dipped down into the 40's at night when I slept. I never had any symptoms. This was sick sinus syndrome.

Since then my pacemaker checks are showing that the pacemaker, which is set at a rate of 60, paces (initiates the atrial heartbeat) 80% of the time. My SA node has gone kaput. New development since March has occurred. I am now having short runs of atrial fib. It's all recorded on this wonderful pacemaker. My atrium's last hurrah, I'm calling it. I'm not happy about it because when it is sustained I am aware of it and I do get dizzy. You see, the heart when it fails, fails from the atrium downward. I sometimes sit here wondering how long I have left before third degree heart block kicks in. This is what happens when you've hung around doctors long enough and "think" you might know almost as much as they do.

nurses are not supposed to show sympathy.

who told you that! sympathy has always been part of a nurses repertoire and there's nothing wrong with it as long as it is kept controlled. i've held many patient hands and shed tears right along with my patients. so have thousands of other nurses and doctors. people expect a human element to the care they receive.