Need some fast help. (Nursing Dx)

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Specializes in Med/Surg, ICU.

I have a paper due Friday and I am just getting hung up on the 5 priority diagnoses. Here's some info about my patient.

He's a 30 year old caucasian male. He came into ER complaining of epigastric pain 5/10, the nurse in ER took his VS and he was 165/95, and had a pulse of 50. They put a holter monitor on him and it shows him in bradycardia. They do an U/S and he's got gall stones and the doctor diagnoses him with cholecystitis and they schedule a laproscopic cholecystectomy for the next morning. However, overnight while he's sleeping his heart rate drops to 30 beats a minute. The guy's 6'3", 235 lbs. He's not extremely overweight, but his BMI shows him as overweight. He says he's active. He says he doesn't smoke, but I know he's lying because he wants to leave the floor and when I walk downstairs for lunch I see him outside smoking.

For my priority diagnoses, I have Acute pain (but have no idea what to put that it's related to without using the medical diagnosis), Knowledge Deficit, because the guy didn't even know he had bradycardia or HTN. I thought I might use "R/T new condition AEB questioning members of health care team" but wasn't sure how that would go over with my instructor.

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?

I know this is a huge post with a bunch of questions, but I can't fail this paper or I fail the class. Any and all help would be greatly appreciated.

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Specializes in Hospice, Oncology.

You could still use pain...r/t obstruction of bile flow, inflammation of gallbladder. As evidenced by wincing, guarding, holding right side. However, you might want to consider Surgery, preoperative care. "Readiness for enhanced KNOWLEDGE of preoperative and postoperative expectations for self care. Just a couple of suggestions. Hopefully you have solved it by now!! Good Luck!:bow:

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Specializes in Med/Surg, ICU.

Thanks! That does help.

Now I'm just concerned about the cardiac element. I'm thinking I picked a bad patient to do this paper on. I didn't realize how hard it would be to come up with a nursing dx on a patient with HTN and bradycardia with no other S/S. I should have went with one of the little ol ladies with 100 meds, I guess. It would have been tedious, but coming up with the care plan would have been easier. (Note: I can figure out the interventions as long as I can come up with the dx.)

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For my priority diagnoses, I have Acute pain (but have no idea what to put that it's related to without using the medical diagnosis),

I frequently use "(relevant body system) disease process" as my R/T criteria, and I've never had an instructor tell me that it was wrong or inappropriate. So for your patient - just on the face of it - I might use "endocrine disease process" as my R/T criteria.

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?

I'm not sure about the "value system" part of it (then again, I can't think of anything better right off hand myself, lol) but otherwise, I don't see why "noncompliance" wouldn't work here.

I'm not sure about the other questions, but I hope this helps you. :)

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Specializes in med/surg, telemetry, IV therapy, mgmt.

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.

[*]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

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

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

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

[*]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

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'm assuming you haven't studied cardiac diseases yet. sustained bradycardia in the 30's is a problem with the sa node of the heart failing to fire. people can literally die in their sleep from this. often there are no symptoms if the patient is sleeping. meanwhile, the brain, deprived of oxygen for a long enough period of time because of the slow heart rate while the patient is asleep, becomes hypoxic, then anoxic and dies. if the patient were awake he would become dizzy and pass out from the low heart rate.

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?

noncompliance
, the nursing diagnosis, is a funny duck. if you read it's definition and etiologies it clearly indicates psychosocial and behavior problems as well as other factors at work preventing the patient from being able to carry out a plan of care. i know this sounds unprofessional but i think of deliberately difficult patients who really would rather be ama (go against medical advice) and problems with insurance companies or interfering relatives and families when it comes to
noncompliance
. with
ineffective health maintenance
the person is inhibited from performing the plan of care by physical and cognitive factors as well as grieving and coping. a patient who is addicted to nicotine and has difficulty stopping smoking is not being
noncompliant
. their physical addiction is affecting their judgment and actions. it is an
ineffective health maintenance
problem.

hope this has answered some of your questions.

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Specializes in Med/Surg, ICU.

Daytonight, I really do appreciate the help! I have just had cardiac med/surg but they didn't go that indepth because I'm supposed to get more specialized in my 8th quarter when I do ACLS. So they failed to mention that sinus brady was an electrical problem. I assumed the "sinus" part mention there was no problem with the electrical current, just that the rate was slow. Also, as I said, he was scheduled to go to surgery for the lap chole the next day, and he did go at the end of my shift before they gave him a pace maker (I have no idea if they ever did). I think another thing that threw me on this was that athletes have bradycardia that is not electrical. It has something to do with the amount of exercise they do and reduced O2 demand...if I remember correctly.

I DO greatly appreciate your help!! This is awesome. Enough for me to finish this tonight. I cannot thank you enough. If you're not an instructor you are definitely missing your calling!! :bow:

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Specializes in med/surg, telemetry, IV therapy, mgmt.

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?

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Specializes in Med/Surg, ICU.

No, he was off the unit when I got back. I don't know if they transferred him to another unit or another hospital. There are 2 TCU floors at my hospital, so he may have been on the other floor when I got back.

The nurse who had him the night before forecasted that he would probably have a pacemaker inserted as well. I just don't know if they ever did or when. I only know that he didn't have it planned yet. Possible that the physician overlooked scheduling it or thought he would probably make it through the surgery. I did think it was sort of weird that they had no cardiac meds for him with the exception of NTG. I'm assuming the NTG was for the HTN, but figured that the one of the S/E of NTG was tachycardia which would be beneficial for HIM.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

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.

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Specializes in Med/Surg, ICU.

This has definitely impacted me enough to want a full cardiac work-up of myself. I live in constant sinus tachy (usually just over 100/bpm), but my B/P is good (around 110-115/70-75). However, I'm a bit overweight at 165lbs and 5'3". My doctor has never seemed concerned or even addressed this with me. I have taken steps to better my health by losing 40 lbs in the last year and keeping it off, but the damage may have already been done. I gained 100 lbs with my pregnancy and it took me over 2 years to even START to take it off (depression and not being in a healthy relationship with my husband played a big role).

Nurses are not supposed to show sympathy, but I'm truly saddened to hear about your heart condition and I appologize if any of my remarks about my patient sounded flippant, because while I did not mean for them to, I realize they may have been construed as such. I hope your health does not decline quickly and that your doctor/s find something to give you a better quality of life.

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Specializes in med/surg, telemetry, IV therapy, mgmt.
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.

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Specializes in Med/Surg, ICU.

My instructors teach that. They tell us we're supposed to show EMPATHY, not sympathy. I'm sorry, I didn't know that was something strictly taught at my school only. They tell us we're only supposed to tell them that we understand that they feel a certain way or that we recognize the existance of their pain, but not to show sympathy.

Personally, I think it's refreshing to hear that I'm being taught something incorrectly. I usually tell my clinical instructor I prefer to assess and question my patient without anyone else in the room for their comfort, but the biggest reason is that I DO show sympathy. I was on a diabetic med/surg floor last quarter and TCU this quarter, so a lot of my patients have been actively dying patients. I didn't mean to give the impression that I act like a robot, but I didn't want to be outted as the sympathetic nurse in the robot world. Know what I mean?

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