Priority diagnosis question from a first time poster.

[It's Just a Ride]

Hello All,

I've been using AllNurses since I began in nursing school but this is my first post. I had a patient in clinical this week and my priority diagnosis isn't completely clear to me.

This elderly patient was in the CCU after an AMI with CHF ~ 45 days prior, history of hypertension, diabetes, family Hx of heart disease. He has a trach/vent in place and appears to be unable to wean due to the potential for right side heart failure.

His heart is the problem. He's on the vent because his heart can't handle the increased workload, SO, I'm thinking Decreased Cardiac Output as my priority, but they've drilled ABC's into our brains so many times a little voice is telling me "B comes before C," but it's the heart, not lungs, that are the real issue. Right?

Also, could I simlpy use AEB AMI, and ventilator dependency? Your insights are appreciated.

[ImKosher]

What's your related factors? What is your A/E/B? Following your ABC, we need to figure out if the airway and lungs is contributing to his condition at all and if it priority. Tell us a little more about the pt.

[It's Just a Ride]

Aside from the Hx I mentioned (HTN, diabetes, fam Hx of heart disease), the pt had no indication of CHF until he was braught in for the AMI. He was described as a stable, critical patient. Stable on the vent, critical off of it.

I was thinking Decreased Cardiac Output or Inneffective Tissue Perfusion, but he is stable currently so those would be "risk for" at the moment, right? A therefor wouldn't be used as primary diagnoses. He's on bedrest, NPO, trach/vent, and was in between an NG and PEG tube placement when I was work with him. He is dependent, alert and oriented, and denied any pain although he had a nasty ulcer on the posterior left wrist from dopamine infiltration.

His airway has some mucus production so I could go that direction. He required suctioning twice while I was there. His breathing is controlled by the vent. His heart is stable provided his lungs have assistance from the vent.

These diagnoses usually make sense to me but after my first day on CCU I'm not sure what direction this should be going.

[fireballnursie]

Insufficient gas exchange related to decreases cardiac function as evidence by inability to ween off artificial life support.

[It's Just a Ride]

I can see this connection. Thank you very much FireBall.

And thank you Kosher for the input.

[nurseprnRN, BSN, RN]

That would be "decreased," "wean," and we don't say "artificial life support" for something like this.

Let's back up here.

How do you know he's on the vent because his right heart might not be able to manage without it? It may be that the work of breathing is just more than he can handle, and if he isn't ventilated mechanically he will not be able to move enough air to stay alive. He is old and has a bad heart, and that resulting weakness may be the reason he's on the vent. The vent doesn't decrease right heart workload per se.

However, decreased cardiac output itself would certainly cause him to be weak. Seems to me that he has at least two priority problems: he can't move enough air to support himself, and his heart is too weak to support any activity. Now, go to your NANDA-I 2012-2014, which every nursing student should have even if his/her faculty neglected to put it on the bookstore list (free 2-day shipping from Amazon), and see what nursing diagnoses fit these defining characteristics. That's how you determine nursing diagnoses-- you identify the defining characteristics by your own assessment, then see what diagnoses they point to. It's just like checking a hematocrit to help make the medical diagnosis of anemia.

I hope you haven't already turned this in, because in my opinion you're a little confused about cause and effect here. Hope we hear back from you.