Nursing Dx help

athena55, BSN, RN · Feb 12, 2009

I am struggling with expanding on my top two nursing Dx for my pt and was hoping someone could help me.
My pt was 73yrs old man, who had COPD, which he has had for 10yrs, ontop of that he has now developed CHF and he has also been in A fib. He has crackles in his bases, dyspnea, edema B/L in feet and legs. He is requiring 4 L of o2 to mainatin SATS of 89%. RR24
I identified 2 DX as
1.Tissue Perfusion, Ineffective Cardiopulmonary R/T dysrhytmias a/e/b pt’s telemetry shows A Fib
2. Cardiac Output, decreased R/T altered rhythm a/e/b dyspnea, crackles
Okay it has been a while since I did care plans:
Nursing Diagnosis
1) Alteration in air exchange AEB need for supplemental oxygen and deteriorating oxygen saturation levels
2) Alteration in cardiac output r/t new onset atrial fibrillation
Plan:
1) Administer oxygen as ordered
Auscultate and document breath sounds q2h
Obtain serial ABG's as ordered
Keep head of bed > 45 degrees/allow patient to assume position of comfort
Assist patient in using conscious, controlled breathing techniques "huff cough"
Administer intravenous fluids as ordered
Provide emotional support
Goal:
1) use of oxygen lowers pulmonary vascular resistance and improves cardiac function and tolerance of ADL's
this position will allow for maximal lung expansion
Inspiratory muscle training is effective in increasing endurance and decreasing dyspnea. Use of the huff technique
(patient does a series of coughs while saying the word "huff") prevents the glottis from closing during the cough and is effective in clearing secretions in the central airways in patients with COPD [Pruitt B, Jacobs M: Clearing away pulmonary secretions, Nursing 35(7);36,2005]
Now do the same for #2!
Best of luck to you,
athena

aerorunner80, ADN, BSN, MSN, APRN · Feb 12, 2009

"2. Cardiac Output, decreased R/T altered rhythm a/e/b dyspnea, crackles"

This doesn't make much sense to me. What is the pt's pulse?

a fib can cause irregular pulses which would lead to tissue perfusion problems.

Not knowing what the pt's pulse is but going off the fact that a fib causes irregularities I would reword your diagnosis.

Decreased cardiac output r/t altered heart rate rhytym aeb irregular pulse(s)

"1.Tissue Perfusion, Ineffective Cardiopulmonary R/T dysrhytmias a/e/b pt's telemetry shows A Fib"

I think a better one for this would be

Ineffective tissue perfusion r/t compromised blood flow aeb irregular heart rate/rhythm.

aerorunner80, ADN, BSN, MSN, APRN · Feb 12, 2009

I am struggling with expanding on my top two nursing Dx for my pt and was hoping someone could help me.
My pt was 73yrs old man, who had COPD, which he has had for 10yrs, ontop of that he has now developed CHF and he has also been in A fib. He has crackles in his bases, dyspnea, edema B/L in feet and legs. He is requiring 4 L of o2 to mainatin SATS of 89%. RR24
I identified 2 DX as
1.Tissue Perfusion, Ineffective Cardiopulmonary R/T dysrhytmias a/e/b pt’s telemetry shows A Fib
2. Cardiac Output, decreased R/T altered rhythm a/e/b dyspnea, crackles
Please don't think I am wanting others to do my work, I am usually good at figuring these out, but I am struggling firstly by thinking of short and measurable goals, as I don't think this can be fixed in a short time. I feel it could certainly improve, but how would that be measured???
Thanks in advance for any help:bowingpur
Yorkshiresrose

OK, nevermind the above post............I'm going to redo it here. I tried editing that post and for some reason it didn't take.

First off, I really question your top two priority dx's. ABC's always get priority and your patient has a known history of COPD. I would redo this with something to do with your airway as your priority.

Think about if your patient codes. Your priority is going to get the breathing going again. You're not going to be worrying about their cardiac output or their tissue perf if they go into respiratory arrest (a huge risk for COPD'ers).

Secondly..........do you have a nursing diagnosis handbook or are you coming up with these on your own?

The reason I ask is because crackles have absolutely nothing to do with decreased cardiac output. Crackles have everything to do with things such as fluid overload (an early sign) and fluid on the lungs though.

Defining characteristics of decreased CO are as follows:

Low blood pressure

Rapid pulse

Dyspnea

Fatigability

Angina

Vertigo

Restlessness

Dysrhythmia (this one is HUGE!!!!!!!!!!!!! especially since your pt has a fib!)

Edema (peripheral, sacral)

Cyanosis (can be caused by ineffective breathing pattern, a fib)

Oliguria

Tissue perfusion...................

I have trouble with you putting down "pt’s telemetry shows A Fib" This just sounds very sloppy and unprofessional to me.

Think about your NORMAL physiology here.

Now think if a fib could possibly compromise blood flow

So................if you have a nursing diagnosis book now is a good time to go there and see that we can't use the term dysrhythmia (I beleive it's a med dx because since we can't diagnose medical conditions such as that) so instead we use R/T compromised blood flow aeb (quite possibly cyanosis and/or altered heart rate and rhythm).

JMHO

ETA: Your PC's, Goals, and Interventions should just fall out of a good nursing diagnosis. It's also nice to refer to your textbooks for those.

Daytonite, BSN, RN · Feb 13, 2009

you have some diagnostic problems here that need correction before addressing short-term goals. before i go on i want to also let you know that there is a care plan sticky thread that you can look at with other examples on it here: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans and post #157 on this older sticky has an explanation about composing goal statements on it:

https://allnurses.com/general-nursing-student/careplans-help-please-121128.html - careplans help please! (with the r\t and aeb)

diagnosing is based upon the signs and symptoms that a patient has that prove the existence of the problem. the signs and symptoms must be there and present in order to assign a nursing diagnosis. i use the analogy that a police detective does not arrest a suspect of a crime unless he has evidence to prove that the suspect did it. it is the same with nursing diagnoses. you cannot say someone has ineffective tissue perfusion, cardiopulmonary or decreased cardiac output unless you have evidence proving that both exist. there is an inherent problem here because you cannot use these two diagnoses together. decreased cardiac output includes the oxygenation and working of the heart cells. ineffective tissue perfusion, cardiopulmonary has to do specifically with the oxygenation of the cells of the lung tissue because of an interruption of the blood flow to the lungs and is used in cases where there are pulmonary emboli causing infarction and death of lung cells. you get many of the same symptoms of chf but chf is a decreased cardiac output problem. it is important that the pathophysiology of the patient's medical condition be understood in order to correctly diagnose the nursing problem. in addition, the nursing diagnosis needs to be understood as well. each nursing diagnosis is only a shorthand label, a suggestion of what the nursing problem is. the more accurate and specific description of the nursing problem is found in its official definition which can be found in the nanda taxonomy. this information is in many currently published care plan and nursing diagnosis books, the appendix of taber's cyclopedic medical dictionary and on two websites that have information for about 80 (in total) of the most commonly used nursing diagnoses that you can access for free:

since a care plan is actually the determination of a patient's nursing problems and strategies to solve them, the nursing process is best used to do that. the nursing process consists of 5 steps and should be followed in sequence.

step 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 and the side effects and complications of medical treatments - chf is a complex disease to understand and is part of a group of heart failures. there is a website that has several pages that addresses the pathophysiology of chf and it took me several times of reading it to understand it all! http://cvphysiology.com/index.html

copd
chf
a fib
medical treatment
- 4 l of o2

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

crackles in his bases
dyspnea
rr 24
sats of 89%
bilateral edema of feet and legs

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - diagnoses should be prioritized by maslow's hierarchy of needs (http://en.wikipedia.org/wiki/maslow's_hierarchy_of_needs). the top 2 diagnoses should be. . .

decreased cardiac output r/t altered stroke volume aeb bilateral edema of feet and legs, dyspnea and crackles in the bases of the lungs
impaired gas exchange r/t alveolar-capillary membrane changes aeb o2 sats of 89%, dyspnea, and rapid respirations of 24

step #3 planning (write measurable goals/outcomes and nursing interventions) - goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing - interventions specifically target the etiology of the problem or abnormal data/signs and symptoms/evidence that supports the existence of the problem - therefore, your goals are always aimed to alter or change the related factor or the signs and symptoms. - for example, with decreased cardiac output you will target the edema of feet and legs, the dyspnea and crackles in the bases of the lungs. you will have interventions for those things. your goals will be to improve or, in some cases, support a symptom that will never improve. how will you know the edema of the feet and legs has improved? well, this is where your initial assessment back in step #1 of the nursing process is important. in assessing a patient with edematous legs i would have taken calf measurements with a tape measure (we used to save the paper ones that came with t.e.d. hose for this very purpose). when measurements are taken daily it can be determined if edema is improving or not. lung sounds can be assessed at routine intervals. how do you know if improvement is made? when the crackles are no longer heard. when did the patient get dyspneic? that would have been discovered during assessment. that improvement is something that is built into the goal statement. a goal is, in a way, an anticipated sign or improvement in a symptom you are putting in writing in positive wording.

there are some problems with the diagnostic statements are you wrote them:

tissue perfusion, ineffective cardiopulmonary r/t dysrhythmias a/e/b pt's telemetry shows a fib

this diagnosis is about a

decrease in oxygenation resulting in the failure to nourish the tissues at the capillary level

(page 228,

nanda-i nursing diagnoses: definitions & classification 2007-2008

). the related factor must indicate why the patient's cells aren't able to get oxygen. for cardiopulmonary it is because the blood coming to the lungs from the heart (the source for all the lung's blood supply) just isn't enough or the blood doesn't have enough oxygen in it. "

dysrhythmias

" doesn't account for a problem

solely

in the lungs. dysrhythmias would affect the entire body. with this diagnosis you are saying that dysrhythmias are causing a problem

only in the lungs

. that can't be true, can it?

"

pt's telemetry shows a fib

" refers to a tool we use. telemetry is an electronic transmission of the heart's electrical impulses. we are interested in knowing the abnormal data that the tool reveals to us. atrial fib is what the tool reveals. now, some instructors may say that atrial fib is a medical diagnosis and you cannot use that in a nursing diagnosis. some instructors may want the term arrhythmia or dysrhythmia used instead.

cardiac output, decreased r/t altered rhythm a/e/b dyspnea, crackles

the problem here is the cause, or related factor, for the

decreased cardiac output

. as the heart fails the cardiac output increases the patient retains fluid (that's the altered stroke volume). that build up and back up of fluid is what gives the patient a congested heart and results in the symptoms of congested lungs and shortness of breath (dyspnea) and then the edema in the feet and legs. the problem is usually due to narrowing in the arteries.