careplan diagnosis 1

7/30/2019 Careplan Diagnosis 1

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NURS 2564 Fall 2012

High Acuity Client Care Plan

List Nursing Diagnosis: Decreased Cardiac output related to altered heart rate/contractility AEB conversion from NSR to atrial

fibrillation

General Goal: Patient will convert back to Normal Sinus Rhythm Measured Goal Outcome: Remain free of side effects from the

medications used to achieve adequate cardiac output

Nursing Interventions Client Response to Interventions

1. Notify the physician immediately of thepatientssudden change in condition. INDEPENDENT

2. Continuously monitor the patients statusINDEPENDENT

3. Monitor and report signs including jugular veindistention, gallop, rales, positive hepatojugularreflux, ascites, heart murmurs, narrow pulse

pressure, cool extremities, tachycardia with pulsusalternans, and irregular heartbeat. INDEPENDENT

4.Administer medication physician has ordered.COLLABERATE

5. Document all information appropriatelyINDEPENDENT

6. Inform immediate supervisor of what ishappeningINDEPENDENT

The physician was notified immediately when the patient converted

The patient remained on continuous monitoring and the Nurse and Imoved closer to thepatients room, we then turned the monitor screen

towards the desk where we were seated.

Patient remained in atrial fibrillation throughout the remainder of the

shift; thepatients blood pressure rose to 155/122 but then returned to amore appropriate level 140/95. The patient remained negative for ascites,

narrow pulse pressure. The patients atrial fibrillation had a rapidventricular rate.

The physician had ordered a Heparin drip to be started immediately12u/kg = 1000units per hour = 30mls per hour

All patient information was documented at the bedside by the nurse

The charge nurse was informed immediately and became a vital asset inassisting with the care of the patient


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7. Monitor daily weight INDEPENDENT

8. Place client in semi-Fowlers or high Fowlersposition with legs down or in a position of comfort.

INDEPENDENT

9. Closely monitor fluid intake, including intravenouslines. Maintain fluid restriction if ordered.

COLLABERATE

10.Monitor lab data, especially arterial blood gases,CBC, electrolytes including sodium, potassium and

magnesium, BUN, Creatinine, and B-type natriureticpeptide (BNP assay).COLLABERATE

11.Observe for symptoms of cardiogenic shock,including impaired mentation, hypotension with

blood pressure lower than 90 mm Hg, decreasedperipheral pulses, cold clammy skin, signs of

pulmonary congestion, and decreased organfunction. If present, notify physician immediately.

COLLABERATE

The patients admit weight the day before was 100kg on the day of

admission and 102.4kg on the day of care

Patient was maintained with HOB up at 30 degrees, not only for

perfusion but also because the patient was receiving nasogastric feedings.The patients condition did not change.

Patients input and output were measured hourly as outlined by the

physician, the nurse hand documented it as well as documented it in the

computer charting system

Lab was drawn after the initiation of thephysicians protocol and thelabs were not available by the end of the clinical shift.

Mentation was unable to be assessed since the patient was sedated, blood

pressure was monitored closely, hourly neurovascular checks were

implemented with no change in peripheral pulses; there was no change inthe patient skin temperature (cool and dry), lung sound remained

diminished bilaterally at the bases. The physician was made aware of thisinformation when he arrived on the floor.


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Evaluation Summary of clients progress toward the measured goal outcome (met; partially met; not met):

Full progress was unable to be assessed at the time of shift change the patient was still in atrial fibrillation with RVR. The goal of

having the patient convert back to normal sinus rhythm was not accomplished. The outcome of having the patient remain free from

side effects of treatment medication was met. Due to the patients overall condition prior to the cardiac conversion and the plans to

fly the patient to an out of state hospital hindered the treatment plan from the physician. The physician was unwilling to prescribe

other medications in fear that the patient would not be able to transfer out of the facility. My Goal was not met. My outcome was

partially met, the patient experienced no side effects from the medication treatment Heparin, however, I was not able to fully assess

because lab data had not yet been posted for review, if I would have had access to the lab data I would have been able to further

analyze how the patient was responding to therapy via lab data. At the end of my clinical day I was able to see that the patient had

not converted and that he was in trouble. Despite my thought process I was unable to determine why the patient was not put on a

cardiac drip to control his rhythm; in my evaluation I do not feel that it is safe to transport the patient out of state.

My Resources and information came fromAckley: Nursing Diagnosis Handbook, 10th Edition

careplan diagnosis 1

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