Nursing Care Plan for pt with vitals in range and nothing wrong after pacemaker inserted

Posted
by rebecca789 (New) New

I need help with my Nursing Care Plan. My pt at clinical was up and about after receiving pacemaker. Had left arm in sling and it didn't hold him back from doing daily routine in hospital room. I don't know what I can diagnose him with.

Magsulfate, BSN, RN

Specializes in ICU. Has 13 years experience. 1,201 Posts

Pacemaker. .. think about why he got a pacemaker. .. That will lead you to a nursing diagnosis.

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 17 years experience. 5 Articles; 10,685 Posts

Welcome to AN! One of the key points of nursing diagnoses is that they are based on the nursing assessment and not the medical diagnosis. The medical diagnosis/procedure may have influence, but is not the reasoning behind the nursing diagnosis. Medical diagnoses look at the problem; nursing diagnoses consider the patient as a whole.

So, what does your nursing assessment tell you about this patient? What might be different now?

rebecca789

4 Posts

ewwww I don't know. The pt. has a bad heart. I got history on him and he has heart stents also. The only problem I observed is that he would not rest. He wanted to leave the hospital as soon as possible. He would get up and walk to the chair, back to the bed, and to the bathroom because he was anxious to gather his belongings to leave. He only talked about work he had to do. He did construction.

Chronic condition is cardiovascular complications. Nursing Diagnosis risk for more health complications and hospital stays related to pacemaker and heart stents as evidence that pt will not rest or stop working long enough to heal.

Awwwww doesn't make sense and his vitals are in range so he probably wont have any health problems to bring him back to the hospital

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 17 years experience. 5 Articles; 10,685 Posts

Do you have a nursing diagnosis handbook? The reason I ask is because what you identified as a nursing diagnosis in your last post is not NANDA approved. You need approved nursing diagnoses from a book that provides the list of the current approved diagnoses.

Now, take a look at your first paragraph. What does that tell you about the patient that would lead you to a NANDA approved nursing diagnosis?

NurseGirl525, ASN, RN

Specializes in ICU. 3,663 Posts

You need a nursing dx book. Preferably the new NANDA 2015-2017. You can't just make up a dx. For somebody with a pacemaker there are about 3-4 dxs you can use. You are going about this the wrong way. You can't just make things up.

rebecca789

4 Posts

I do not have a Nursing Diagnosis handbook. I am waiting until I get the rest of my loan money from school on the 15th to buy one. I read my last comment. I think a better Diagnosis is Fatigue. I checked that one is NANDA approved. His body has gone through a lot. He has a pacemaker and heart stents. Getting the pacemaker is going to be stressful on his chest area and heart. The body should take it easy. He does not want to rest. He may become fatigued from not stopping while his body is adjusting to the new object lodged under his skin shocking his heart.

I didn't mention it before but he also eats a lot of fast food because he doesn't have time to stop and cook because he works too much. Some education in Nutrition is needed. I can add that into the care plan too. People with heart problems need less sodium and more protein? I'll look up healthy diets for heart patients today.

sailornurse

Specializes in ER/Tele, Med-Surg, Faculty, Urgent Care. Has 39 years experience. 1,231 Posts

What about his skin where they inserted the pacemaker? Any potential problems here? I am giving you big hints. Also, do you think this procedure is painfree?

Alisonisayoshi, LVN

Specializes in LTC. 547 Posts

You definitely need a dx book, possibly a care planning book. My care planning book got me through school, and was regularly borrowed by classmates.

Education=knowledge deficit

As pp stated, he hurts, it's not a pain free deal.

Um, did we open the skin? Impaired skin integrity, or risk for infection works in those places.

You can't really care plan without a book, I mean, now I do, with check boxes in a EHR, but in school, the book is essential. Really. It's needed. Until you have a book, Google is your buddy.

rebecca789

4 Posts

Thank you for the comments. I was not able to see the incision site of the pacemaker because it was still bandaged before my clinical was over. The RN told me she could not take it off because the doctor is the one that takes the bandage off after the procedure. The man was not in pain when he was with me. I gave him his meds for the morning and none were pain meds. Pain was never anything I thought as a diagnosis for the pt, but I can imagine later when the bandage is off that the skin can be tender, painful, and at risk for infection. Thanks for making me see a bigger picture. I'm trying very hard to think like a nurse. I feel like it's going to take forever though. I know I need a Diagnosis book. I will buy one as soon as I get my loan money.