Please Help-Nursing Care Plan

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Hi this is my first time using this. I need help.

My patient is 62 year old male. Had stroke in 2004 & now hasimpaired communication & Right sided weakness. He's had a CABG & mitral valve replacement. Also has A. Fibrillation. Patient presented to hospital with abdominal pain & felt his heart fluttering. CT scan revealed L atrial thrombus. He has been recieving Heparin drip & Coumadin & will be released tomorrow as labs are fine. He complains of SOB, but his respirations are even & look unlabored. Clear lung sounds bilaterally. O2sat 98% room air. Capillary refill example: Ineffective (specify) Tissue Perfusion. what should I put in this slot? Risk for Ineffective Total Body Tissue Perfusion? Is this just too far fetched? Need help. Thanks

Oh, my patient also has HTN. No DM. Also had cardiac stents placed in mitral valve

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

care planning is all about determining a patient's nursing problems and coming up with strategies to help improve, stabilize or support their deterioration. we have the nursing process to help us accomplish this. the nursing process is a tool. it has 5 steps and the first 3, when followed in sequence, is going to help you with this. in addition, you have two issues to deal with: understanding the pathophysiology going on and knowing how the nanda diagnoses are used and applied to a situation.

i expand on the 5 steps of the nursing process for care planning as follows. i recommend that you do what each step tells you to do before moving on to the next:

  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.
    • https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites

[*]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.
  • your instructors might have given it to you.
  • you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  • many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  • the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  • there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:

[*]planning (write measurable goals/outcomes and nursing interventions)

  • goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
    • improve the problem or remedy/cure it
    • stabilize it
    • support its deterioration

    [*]interventions are of four types

    • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    • care/perform/provide/assist (performing actual patient care)
    • teach/educate/instruct/supervise (educating patient or caregiver)
    • manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

step #1 assessment - look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology - this patient has oxygen perfusion problems, but where do they start? the first step of the nursing process requires you to know what is going on physiologically with the patient. so, read up on the diseases, conditions and the procedures that were performed. this answer begins with this man's heart.

  • htn
  • left atrial thrombus
  • had cardiac stents placed in mitral valve
  • had a cabg & mitral valve replacement
  • atrial fibrillation
  • history of stroke in 2004

step #2 determine the patient's problem(s)/nursing diagnosis(es) - part 1 - make a list of the abnormal assessment data you collected - i compiled this list from what you posted and grouped some of the symptoms together. a few things stick out like a sore thumb to me, mostly because i worked with these types of patients before. the heart fluttering, sob, slow capillary refill and edema are symptoms of heart failure. the root of the cause is the heart. the fact that they stented his atrial valve confirms that his ticker is doing poorly. did you look up atrial fibrillation and the complications of it (blood clots, stroke). that and his history of a stroke is in part why he is being anticoagulated. do you understand why he was stented?

  • heart fluttering
  • complains of sob
  • capillary refill
  • has edema in hands and feet
  • abdominal pain
  • impaired communication
  • right sided weakness

step #2 determine the patient's problem(s)/nursing diagnosis(es) - part 2 - decide on the nursing diagnoses to use, match your abnormal assessment data to likely nursing diagnoses - this is where i think you are having your problem--deciding on the nursing diagnosis to use. read on.

every nursing diagnosis has a definition. there are actually two nursing diagnoses that concern oxygenation of tissues in the body. they are

read the definition of each. read the defining characteristics listed with decreased cardiac output and you are going to find that the patient's heart fluttering, complains of sob, capillary refill

the decreased cardiac output diagnosis is used specifically for heart problems. ineffective tissue perfusion (specify type) is used for everything else, i.e. peripheral vascular disease, blood clots lodged in other places than the heart.

now, you still have to diagnose this patient's abdominal pain and address his issues of impaired communication and right sided weakness. do you also need help with those?

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Nope, I think I've got it. Thank you so much for going step-by step to help me understand. You really answered a lot of my questions. Thank you again so muc for your time & your reply. I have learned from your great teaching! Sorry response so late. God bless!

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