question regarding care plan

Esme12, ASN, BSN, RN · Mar 14, 2013

Hi people,
I am stumped on this care plan. My pt woke up c/o chest pain an hour before he arrived to hospital. He was given two NTG by ems prior. He got diagnosed with STEMI and got emergent PCI. Two stents were placed in LAD and an IABP and had a transvenous pacemaker in him and he is on the vent. He had a hx of htn, dm, and high cholesterol. 51 year old.
We have to pick three dx and prioritize which one are the most important. I picked:
Nursing Dx #1
Decreased Cardiac Output r/t myocardial injury secondary to AMI aeb decreased in BP, elevation in HR, dyspnea, dysrhythmias, diminished pulses, pulmonary edema, and elevation in CK-MB and Troponin levels.
Nursing Dx #2
Ineffective Tissue Perfusion r/t cardiac ischemia, interrupted blood flow and impaired transport of oxygen aeb 100% occlusion of LAD, decrease in CO, EF

Nursing Dx #3
Deficient knowledge r/t family unfamiliarity with procedure of PCI and IABP, with new condition: AMI, treatment, and the complexity of the treatment aeb family anxiety and stress about patient current status, family questioning RN about PCI and IABP regarding how the treatment works and how the treatment helps patient, RN providing written information about the treatment and MI, and RN demonstrates to family members how IABP machine looks like and what each signal/button indicates.
But I'm confused because would he still have decrease CO considered he already have a balloon pump? Would he still have ineffective perfusion considered he is on the vent? Is deficient knowledge really an important diagnoses consider all that is going with this patient? I am also stumped that he has bloody drainage around his member but has no sign of infection. No elevated WBC, no fever, nothing. So what can cause bloody drainage? Low level UTI?, prostate problem?, kindney problem? Please help, I'm pulling out my hair!

I know I have told you before.....the care plan is all about the patient assessment of the patient and how it applies to the patients diagnosis. Are these diagnosis that we provided to you or you gave your patient based on the assessment.https://allnurses.com/nursing-student-assistance/stuck-careplan-help-697466.html#post6364564

What is this patients underlying diagnosis?

They came to the ED with a complaint of CP got rushed to the Cath Lab. The patient suffered a massive MI AEB ejection fraction is less than 15% the patient is intubated and on a ventilator and has gone through an invasive intervention.

When a heart attack is bad enough the heart goes into shock..... what is cardiogenic shock? what is the treatment for cardiogenic shock? What is an IABP...what does it do? Is this patient on any meds to elevate the B/P? Are they still having pulmonary edema?

Yes a patient can still have a decreased cardiac output even with the IABP if there was extensive damage to the myocardium...the IABP helps the heart rest and heal but the damage is done.

My question is does this patient still have ineffective tissue perfusion now that they have had their PCI....the blockage is gone correct? Could they have ineffective tissue perfusion related to the poor EF? The balloon pump in the femoral artery to the affected extremity. Are the still having chest pain after the procedure? Could poor perfusion be caused from a poor EF?

I am guessing that this patient coded, somewhere along the line, from a 100% occluded LAD was intubated. They suffered a massive MI went to cath lab had a PCI.....despite intervention the remained unstable and in cardiogenic shock a balloon pump was inserted and the patient transferred to ICU. I will bet he has a foley and sometimes if a male has an enlarged prostate it is difficult to pass they foley and if there is some trauma upon insertion that can lead to some bleeding around the meatus. OR they are hypercoagulated due to the procedure and IABP and need their coags rechecked. Knowledge deficit can be the patient and the family. Their loved one is critically ill...their lives have changed forever.

so tell me about your patient.....what is a priority for this patient. https://allnurses.com/nursing-student-assistance/nursing-care-plan-820899.html

ctran · Mar 21, 2013

Since I have failed my ICU paper, I realized I am not going to be a nurse. If I cannot even pass a care plan or know how to properly diagnosed my patient, how can I be a good nurse? I thank you for helping me out but I guess I just don't get it. Thank you very much.

Esme12, ASN, BSN, RN · Mar 21, 2013

What did you miss? Where in the process are you going off course?

Care plans aren't that bad.....many students start off with the medical diagnosis and work backward or pick a diagnosis then try to fit the patient into it.

These can help you know and follow what information is important....thank you daytonite...

critical thinking flow sheet for nursing students

student clinical report sheet for one patient

You are just learning......what semester are you?

TGell me the assessment of this patient and I can break it down for you...maybe help you see what you are missing.

ctran · Mar 21, 2013

Hi Esme12,

I'm in 3rd semester right now. Patient is 51 year old male came into ER c/o of chest pain starting an hour ago that woke him up from bed. He c/o of blurry vision and sob. Patient was given asa and ntg by ems on the way to the hospital. 2 ntg were given prior to arrival by ems. Pain was located in central chest and radiated to the right arm. MI suspected due to EKG showing tachycardia and ST elevation and increasing cardiac markers such as CK-MB and Troponin. When confirmed patient is having a STEMI due to anterior MI, patient was send into cath lab and found the LAD was 100% occluded. Ecchocardiogram also showed patient has an EF

Neuro:

GSC 9 with sedation. Able to follow command. Alert and able to nod or shake head when nurse asked simple questions. PERRLA, move all extremities.

CV: cap refill is

Pain: FLACC 0, monitoring chest pain

GI: NPO. NG tube on low cont. suction. Coffee ground residual

Genitourinary: Foley cath. Adequate UO -dark yellow and cloudy; bloody drainage around member. 240cc UO

Resp.: mechanically vent. at rate of 20 bpm. Auscultation revealed rhonchi bilaterally and diminished bases. Despite mechnical vent, patient's O2 continously dropped.

Integ: pale skin but warm and dry. Surgical sites are clean and dry. No inflammation noted. Denied pain when palpated area around surgical sites. No swelling noted.

Musculoskeletal: Bed rest. Lower extremities must by lay flat due to femoral arteries puncture sites for cath and pacemaker insertion. Able to move upper extremities. Bilateral equal strength. Normal strength and tone and no CVA tenderness.

v/s:

time : BP HR RR Temp. SpO2

1200 112/69 74 20 98.3 100

1300 109/72 70 20 97

1400 94/71 70 20 97

1500 81/52 72 20 94

When I mentioned that patient pp are narrowing she told me that they are trying to wean pt off levophed and he also had alot of secretion and his HOB was at 0 degree. So in order to increase O2 they put him in reversed trendelenberg.

His mech vent is set at

FiO2 70% rate 20 Pressure support 15 PEEP 30/10 Mode pressure control vent

Type of airway ET tube size of airway 7.5

His ABG results

pH: 7.19 pO2: 71.3 pCO2: 41.2 HCO3: 15.4 BE: -12.2 O2 sat: 88

For this I said he was in uncompensated metabolic acidosis

His lab is

Normal Na+ and Cl

CO2 is 19 low

BUN 25 high

Normal Creatinin

glucose 358 high

Albumin 3.2 low

PTT is 22.4 low

CPK 1332 high

Troponin 29 high

ctran · Mar 21, 2013

My instructor emailed me that basically all my points deducted were in the care planning section. I'm trying to study for my second exam but basically my mind is on this paper now and can't seem to concentrate

Esme12, ASN, BSN, RN · Mar 21, 2013

Study for your test.....when do you take it?

ctran · Mar 22, 2013

This coming wednesday. I'm meeting with my instructor after the exam to talk about the paper. I'm so afraid right now because if I don't pass the icu paper, I'm out of the nursing program. I have one last chance to resubmit it.

Esme12, ASN, BSN, RN · Mar 22, 2013

Hi Esme12,
Patient is 51 year old male came into ER c/o of chest pain starting an hour ago that woke him up from bed. He c/o of blurry vision and sob. Patient was given asa and ntg by ems on the way to the hospital. 2 ntg were given prior to arrival by ems. Pain was located in central chest and radiated to the right arm. MI suspected due to EKG showing tachycardia and ST elevation and increasing cardiac markers such as CK-MB and Troponin. When confirmed patient is having a STEMI due to anterior MI, patient was send into cath lab and found the LAD was 100% occluded. Echocardiogram also showed patient has an EF

Neuro:
GSC 9 with sedation. Able to follow command. Alert and able to nod or shake head when nurse asked simple questions. PERRLA, move all extremities.
CV: cap refill is
Pain: FLACC 0, monitoring chest pain
GI: NPO. NG tube on low cont. suction. Coffee ground residual
Genitourinary: Foley cath. Adequate UO -dark yellow and cloudy; bloody drainage around member. 240cc UO
Resp.: mechanically vent. at rate of 20 bpm. Auscultation revealed rhonchi bilaterally and diminished bases. Despite mechnical vent, patient's O2 continously dropped.
Integ: pale skin but warm and dry. Surgical sites are clean and dry. No inflammation noted. Denied pain when palpated area around surgical sites. No swelling noted.
Musculoskeletal: Bed rest. Lower extremities must by lay flat due to femoral arteries puncture sites for cath and pacemaker insertion. Able to move upper extremities. Bilateral equal strength. Normal strength and tone and no CVA tenderness.

v/s: Is this augmented (IABP pressure?)
time : BP HR RR SpO2
1200 112/69 74 20 100
1300 109/72 70 20 97
1400 94/71, 70, 20, 97
1500 81/52, 72, 20, 94

When I mentioned that patient pp are narrowing she told me that they are trying to wean pt off levophed and he also had alot of secretion and his HOB was at 0 degree. So in order to increase O2 they put him in reversed trendelenberg.

His mech vent is set at
FiO2 70% rate 20 Pressure support 15 PEEP 30/10 Mode pressure control vent (What was his title volume?)

Type of airway ET tube size of airway 7.5

His ABG results
pH: 7.19 pO2: 71.3 pCO2: 41.2 HCO3: 15.4 BE: -12.2 O2 sat: 88
For this I said he was in uncompensated metabolic acidosis

His lab is

Normal Na+ and Cl
CO2 is 19 low
BUN 25 high
Normal Creatinin
glucose 358 high
Albumin 3.2 low
PTT is 22.4 low
CPK 1332 high
Troponin 29 high

Another question......What meds is this patient on? Did they have a PA line (swan ganz)?

I have highlighted important information.

Now, looking at what I highlighted......what do you think think patient needs....forget about the NANDA I diagnosis....what do you think they NEED. What is important? What is alarming about this information