Need help with dx (abnormal assessment data)

[MattiesMama]

My patient today had a very irregular HB...The only way to describe it is, it kinda went "lub-dub-lub" and then a pause...then the pause would be at a varying length before the next contraction would begin, and it was always the three sounds grouped together like that. I did not get the apical rate because I didn't know how to count it...Do you just count each sequence of 3 as one contraction? I know this is probobly a stupid question but we have only been taught how to count a normal heartbeat, not an irregular one....and is there a website or something that has an audio of the different types of heart abnormalities? So in the future I don't look like a doofus when I'm trying to describe them to the nurses?

Anyways, her periphreal pulses were weak and thready and pedal pulses not palpable. Blood pressure was extremely difficult to measure but I got it at 140/72...but everything else was normal. She has a dx of diabetes, hypertension and hyperlipidemia, and bacteremia, but no history of any heart problems. What could be causing this? And what could I do for a NANDA? I was thinking "Decreased cardiac output r/t alteration in heart rate, rhythm and conduction AEB cardiac arrythmia, weak and thready periphreal pulses"

When I go back tommorow, I will have the same pt...are there other things I should be assessing that might help with the dx?

[gt4everpn, BSN, RN]

Your nursing dx is on point, yes decreased cardiac output is one. You should have notified the M.D of such an abnormal heart beat seeing that she does not have a dx of heart failure or any other heart problems, HTN wouldn't cause the heart to beat in such a way. You assess an irregular heart beat just as you assess a regular heart beat...listen for a heartbeat and count how many times for that minute you heard a heartbeat, if you think you heard 3 heartbeats then you heard 3 heartbeats, if your still unsure have another nurse listen as well

I have a great website that has normal and abnormal heart sounds.. here it is

http://www.med.ucla.edu/wilkes/intro.html

[MattiesMama]

Thanks for the website!

I don't think I explained this well though...you know how a normal HB sounds like "lub-dub" and you count each lub-dub as one HB? She had something that sounded like "lub-dub-lub" for each beat... So basically, it was like one of the AV valves was closing late. Could that be atrial fibrilation?

I had my instructor listen to it and she said "yeah, it's very irregular, let's look at her chart and see what is on there". I told her that there was nothing in the chart, so she said to check her med orders to see if it was a side effect? I was thinking the same thing as you to be honest, I would have contacted the MD right away, but there really wasn't much I could do...I'm assuming that she at least told the charge nurse but I'm definately going to follow up on it tommorow.

[gt4everpn, BSN, RN]

She maybe has an S3 or an S4 which are both extra and abnormal heart sounds. S3 occurs mostly in CHF whereas S4 occurs in HTN or CAD. Maybe you heard an S4 which occurs before S1 or the lub sound, but could sound like lub-dub-dub. Did you get to listen to the sounds on the link ?, did any sound familiar? I thought you meant her heart paused then beat a couple of times. Good learning opportunity though.. good assessment !!!

[MattiesMama]

Ugh, the volume seems to be broken on my computer so I can't hear it! Off to find my headphones, lol!

[Daytonite, BSN, RN]

we are nurses not doctors. nursing diagnoses are based upon the symptoms that the patients has. we need to know the pathophysiology of the symptoms for the related factor part of the nursing diagnostic statement, not to diagnose the patient. the nursing diagnosis is decreased cardiac output r/t altered heart rate aeb irregular heart rate of __. weak and thready peripheral pulses are a defining characteristic of ineffective tissue perfusion, peripheral r/t interrupted blood flow.

when i go back tomorrow, i will have the same pt...are there other things i should be assessing that might help with the dx?

which diagnosis? the medical diagnosis of hypertension? see

http://www.fpnotebook.com/cv/endo/hyprtnsnindbtsmlts.htm

and symptoms of arrhythmias:

http://www.fpnotebook.com/cv/sports/arhythmsinathlts.htm

. or the nursing diagnosis of

decreased cardiac output

? see the defining characteristics listed here:

decreased cardiac output

or the nursing diagnosis of

ineffective tissue perfusion

? see the defining characteristics listed here:

ineffective tissue perfusion specify type: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral

[MattiesMama]

Dayonite that's funny because my clinical instructor said the same exact thing! She told me sit down and look at the entire clinical picture of this patient before you start fixating on the heartbeat...which I did and she has like 3 diagnoses that have arrythmia as a common co-occurance. Apparently they do know about it but have decided that given her state of health the risks of getting a pacemaker outweigh the benefits...

I ended up doing innefective peripheral tissue perfusion as a DX, since that had the most supportive evidence.

[Daytonite, BSN, RN]

there you go. our focus as nurses is how the patient's disease is affecting their response to their surroundings and helping them deal with how to live their life--not to heal their disease. we may assist the doctor in the treatment of their disease, but our primary purpose is to help the person deal with what they got dealt. if you start looking at the nursing diagnoses, goals and nursing interventions that way, then you have nailed what our nursing job is all about.