ICU care plan- please please please help!!

  1. Hi all,
    I'm trying my luck on here to see if I can get some help. As always I don't want anyone else to do my work for me- I just need some help getting started with coming up with interventions for my patient. Care plan is due later this week so I'm getting a jump on it now.
    Brief patient review: elderly man in his 80's, past 1-2 pack a day smoker who came in for dyspnea and aortic valve replacement.
    PMH: CHF, Coronary artery disease, diabetes mellitus, cerebreal vascular accident (2 years ago; functional but has left sided weakness), hypertension, left bundle branch block on EKG, aortic valvular stenosis, cancer (leading to a right middle lobectomy & skin graft on the scalp in 2006, currently cancer free); mitral valve regurgitation, diverticulitis, and <35% ejection fraction.
    Went into cardiogenic shock after having his Aortic valve replaced- they wanted to get to his mitral valve but couldn't because he wasn't stable enough in the OR. He went to the ICU post procedure where he had difficulty maintaining proper gas exchange due to cardiogenic shock, so they did a tracheostomy and put him on SIMV. He ended up going to renal failure, so they put him on continuous vein to vein hemofiltration (or CVVH, whatever that stands for).
    So, I have two nursing diagnoses for this patient, both of which have been approved and recommended for use by my instructor.
    1) [FONT='Arial Narrow']Altered tissue perfusion (less than body requirement), related to decreased cardiac output secondary to cardiogenic shock
    [FONT='Arial Narrow']2) [FONT='Arial Narrow']Impaired gas exchange related to pulmonary congestion secondary to cardiogenic shock
    [FONT='Arial Narrow'][FONT='Arial Narrow']My instructor wants me to come up with interventions to promote perfusion to his organs (diagnosis 1) in particular his kidneys and his stomach via the various arteries like the mesenteric arteries, etc. I know that the lower tier of dopamine (less than 5mcg/kg/min) promotes renal perfusion, and i have that as an intervention...and, I'm monitoring his hemodynamics of course....but so far, that's it. I'm soooo lost. Can someone please please plase help me come up with nursing interventions for these two diagnoses for this patient? I'm espeically looking for the pharmacological ones, in addition to the typical nursing skills and nursing judgements, etc.THANK YOU SO MUCH!!!!!
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    About texasnursingstudent

    Joined: Jul '06; Posts: 35; Likes: 9
    Specialty: Being bossed around during clinicals.


  3. by   Daytonite
    cvvh is continuous venovenous hemofiltration, a form of hemodialysis. there is a description of it on this website:
    the slow continuous process of cvvh has a low risk of inducing hemodynamic instability in a patient who is already hemodynamically compromised when compared to conventional intermittent hemodialysis. - cardiogenic shock - concept map of cardiac output - management of pulmonary edema

    drug therapy for cardiogenic shock includes vasopressors and inotropics to maintain organ perfusion. as for the medications to encourage the re-perfusion of his organs, vasopressors and inotropics (to improve the contractility of the heart) are generally given. - congestive heart failure - drugs used in treating shock and cardiogenic shock
    examples of drugs that will increase the contractility and/or ventricular performance of the heart are:
    • cardiac glycosides and catecholamine which increase the rate and force of cardiac contractions
    • isoproterenol (isuprel)
    • dopamine (intropin)
    • dobutamine (dobutrex)
    • norepinephrine (levophed)
    • phenylephrine (neo-synephrine)
    • milrinone (primacor)
    • amrinone (inocor) -about dopamine in cardiac - about dobutamine in cardiac - about aminone in cardiac - about epinephrine in cardiac - about isoproterenol in cardiac - about norepinephrine in cardiac - in case you want to see more listings of cardiac medications

    i would suggest that decreased cardiac output would be a better nursing diagnosis to use for this patient. this nursing diagnosis covers pulmonary congestion and and the tissue perfusion problems of cardiogenic shock. the reason i say this is because if the doctors correct his cardiac problem, the pulmonary congestion and tissue perfusion problems are also corrected, are they not? therefore, the major problem is cardiac, not one of problems with the capillaries at the local level which is what altered tissue perfusion (or, in official nanda language: ineffective tissue perfusion) covers. therefore, i would change the first diagnosis to: decreased cardiac output related to altered afterload and altered contractility secondary to cardiogenic shock as evidenced by [cold/clammy skin, shortness of breath/dyspnea, oliguria, prolonged capillary refill, decreased peripheral pulses, variations in blood pressure readings, increased/decreased systemic vascular resistance, increased/decreased pulmonary vascular resistance, skin color changes, crackles, cough, orthopnea/paroxysmal nocturnal dyspnea, cardiac output less that 4l per minute, cardiac index less than 2.5l per minute, decreased ejection fraction, decreased stroke volume index, decreased left ventricular stroke work index, presence of s3 or s4 sounds, anxiety, restlessness--page 26, nursing diagnoses: definitions & classification 2005-2006 published by nanda international] i've listed the defining characteristics from my nanda resource after the aeb part of the diagnostic statement because some of these are the assessment problems that you should have found in your patient and for which you need to develop your nursing interventions. you can find some nursing interventions at these websites:

    impaired gas exchange related to pulmonary congestion secondary to cardiogenic shock is not proper nanda language. the correct language should be impaired gas exchange r/t ventilation-perfusion imbalance secondary to cardiogenic shock aeb [visual disturbances, decreased carbon dioxide, tachycardia, hypercapnia, restlessness, somnolence, irritability, hypoxia, confusion, dyspnea, abnormal arterial blood gases, cyanosis, abnormal skin colors such as pale or dusky, hypoxemia, hypercarbia, headache upon awakening, abnormal rate rhythm and depth of breathing, diaphoresis, abnormal arterial ph, nasal flaring--page 83, nursing diagnoses: definitions & classification 2005-2006 published by nanda international] again, i've listed the defining characteristics from my nanda resource after the aeb part of the diagnostic statement because some of these are the assessment problems that you should have found in your patient and for which you need to develop your nursing interventions. you can find some nursing interventions at these websites:

    suggestions for other nursing diagnoses that might apply here would be:
    • ineffective airway clearance
    • ineffective breathing pattern
    • impaired verbal communication [because of the tracheostomy]
    i've given you links to websites where you can find nursing interventions for the nursing diagnoses. some ideas to keep in mind as you develop your nursing interventions:
    • the goal of medical treatment will be to improve cardiac output and make sure the left venticle of the heart is emptying. if that does not improve with drug therapy, an intraaortic balloon pump may be inserted to facilitate this.
    • monitor the blood pressure constantly
    • you'll be giving vasopressors and inotropics as prescribed to maintain organ perfusion
    • keep monitoring arterial blood gases and treating any imbalances
    • monitor urinary output
    • monitor distal pulses
    • maintain the right atrial catheter (swan-ganz) which will be there to help the doctors assess his level of heart failure
    in the event that you want to go with your original nursing diagnosis of altered tissue perfusion (nanda: ineffective tissue perfusion: peripheral, renal, gastrointestinal, cardiopulmonary, cerebral [pick one or more]) here are links to nursing interventions for them. i would say, however, that you are not going to find the interventions you need at these sites because this nursing diagnosis is not adequate to cover what is going on with the patient. i have no explanation for why your instructor would have approved this diagnosis unless there are other things going on with this patient that i am not aware of.
  4. by   texasnursingstudent
    Thanks daytonite.
    I appreciate all your advice and all of the sites you provided. I am sure I'll end up using them for the rationale when I am finishing up my care plan. While I do fully agree with you on your nursing suggestion (that I do decreased cardiac output instead) the instructor I have is insisting that I am using these two I guess I can't really argue with that, although I do agree with you- your suggestion encompasses more and would make so much more sense!!!! She's been an ICU nurse forevvvvvvvvvvvvvvvvver and is stuck on the idea that this is the right thing to do.....Sigh. Frustration.

    I really appreciate your suggestion for rewording my ineffective tissue perfussion diagnosis. You are correct; the wording I was using was incorrect and not compliant with the NANDA wording (same for the one about the perfusion one). Even though I really don't want to go with this one, after I reword it I am going to have to. I'm not sure if I understand what you mean by ventilation-perfussion mismatch (sorry, its late and I'm pretty sleep deprived)- I assume by that you mean that the patient is getting the oxygen/air they needed, but it just isn't "perfusing" across the alveolar membrane. Please correct me if I am wrong, or let me know if I am right, if you have time to- I am sure you are quite busy.

    Once again- Thanks again SO MUCH for your helpful suggestions and support!! I really really appreciate it! As always I am open to suggestions from anyone else no matter what their expertise-- any bit helps!
  5. by   Daytonite
    I gotcha! Well, maybe she's knowing something about using the Ineffective tissue perfusion diagnosis that I don't, especially if she's had experience working in ICU and with hemodynamic monitoring. You need to understand that writing these care plans for school can end up being extremely creative. The main focus that some instructors are looking for is that you understand how all the elements blend together and represent the nursing process.

    So, I guess you'll need to use Ineffective Tissue Perfusion: Cardiopulmonary, Renal and Gastrointestinal R/T mechanical reduction of arterial blood flow AEB [altered repiratory rate outside of acceptable parameters, use of accessory muscles, capillary refill greater than 3 seconds, abnormal arterial blood gases, chest pain, sense of "impending doom", bronchospasm, dyspnea, arrhythmias, nasal flaring, chest retraction, altered blood pressure outside of acceptable parameters, hematuria, oliguria or anuria, elevated BUN or creatinine ratio, hypoactive or absent bowel sounds, nausea, abdominal distention, abdominal pain or tenderness--page 206, Nursing Diagnoses: Definitions & Classification 2005-2006 published by NANDA International]. See, the problem I have with using this diagnosis is that the defining characteristics really do not match with what is going on with your patient's hemodynamic problems of hypotension and the decreased cardiac output and stroke volume. That, is his major problem to my way of thinking. I'd like to get my hands on one of her ICU care plans to see how she's care planning hemodynamic problems like this. Everything I know is screaming at me that this fellow has a huge cardiac output problem as a result of his mitral valve surgery. What I would do, if I were you, is just use the nursing diagnosis as she wants and include the assessment data that pertains to all his perfusion problems as your AEB items. In other words, just rob what you need from the Decreased Cardiac Output stuff I suggested and tack it onto the Ineffective Tissue Perfusion diagnosis.

    Part of the aggravation of writing these diagnostic statements is in the wording you use. The "related to" part has to be a short, concise couple of words that sums up what the assessment data is showing. Or, in other words, it's the cause of the nursing diagnosis or problem going on. You can lie awake nights trying to figure out the right wording to use. That's why it's helpful to have care plan books and NANDA guides to help out because they've already done that part of it for you. Still, I'll find stuff using different wording, particularly in older care plan books. So, that sent me back to an older copy of a Carpenito care plan book that I have. Here's an idea for you:
    • Ineffective Tissue Perfusion: Cardiopulmonary, Renal and Gastrointestional R/T pulmonary congestion and decreased renal flow secondary to cardiogenic shock
    How does that sound?

    The wording "ventilation-perfusion imbalance" comes directly out of NANDA resources for the related factors of the Impaired Gas Exchange diagnosis. You will find this terminology used in recently published care plan books as well. You will see it on the website for the Ackley/Ladwig care plan site link I listed for you on the post above. What it means is that the patient is breathing, but not exchanging carbon dioxide and oxygen in the right balance. The other related factor that NANDA has listed for this diagnosis is alveolar-capillary membrane changes. Unless your patient has some sort of lung disease such as emphysema then you really can't use that. The definition of this diagnosis is "excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane." (Nursing Diagnoses: Definitions & Classification 2005-2006 published by NANDA International, page 83.) The way that is measured is through ABGs and, of course, physical assessment (I listed all the defining characteristics in my previous post). You might use "oxygen-carbon dioxide imbalance and insufficient [or poor] perfusion" in place of the "ventilation-perfusion imbalance".

    I have a feeling that after this assignment you will NEVER forget about cardiogenic shock and it's treatment!
  6. by   `NurseConnie33
    wow daytonite,

    you are so helpful. although this post is from years back, it is so informative. thank you so much for all that you do to help flourish.
  7. by   nerdtonurse?
    Daytonite passed away some time ago, but her posts helped me during school so much...miss ya....