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Untitled Prezi

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Wendy Dean

on 6 May 2013

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Pathophysiology In atrial fibrillation the normal signals that are produced
by the sinus node is overwhelmed by rapid electrical changes causing an irregular heart rhythm. Basic Conditioning Factors Pt. Initials: JWW
Pt. is a full code
•68 years old,
•Patient lives alone and has two grown daughters. One lives in Anderson and the other lives in Illinois. Patient works outside his home and has medical insurance.
•Integrity vs. Despair
•Patient’s atrial fibrillation is under control with medication and waiting fever to dissipate so a cardiac catheterization can take place.
•Patient has family support. His daughter visits often and patient has health insurance. Assessment Patient Situation:
Patient presented to the emergency room with rectal bleeding from colon mass. During patients colonoscopy patient heart rhythm went into atrial fibrillation. Patient's O2 stats dropped and patient complained of difficulty breathing. Patient was transferred to ICU for this reason. Subjective History •Patient Allergies: No Known Allergies-No Know Drug Allergies-No known food Allergies, No Know Environmental Allergies
•Past & Present Medical History: High Cholesterol, High Lipids, Heart Catheterization, Blockage, Anxiety, Depression, Diabetes Type 2, Blood in Stool, Family History of Cardiovascular Disease and Diabetes, Urine Urgency, Former Smoker, Had Chicken Pox as a child, Flu Shot in 2012.
•Review of Systems:
Neuro: WNL except for patient wears corrective lenses, Oriented to person, place and year, no hx of falls
Cardio: WNL, Sinus Rhythm, regular rate, no edema, cap refill < 3 seconds, pulses equal and strong throughout
Respiratory: WNL except for patients on NC 4 liters. Lungs clear throughout, equal chest expansion, easy respiration's
GU/GI/Skin/Wound: WNL except for patient using urinal, blood in stool of last BM (3/11), restricted carb diet. No restraints, No dentures, elastic skin, dry and warm Nursing 3360 Care Map Wendy Dean Medications oBisoprolol – Zebeta
5 mg – 2 tab oral BID
Side effects
1.Vertigo
2.Ventricular dysrhythmias
3.hypotension
Pharmacological class: selective beta 1 blocker
oDiltiazem – Cardizem
120 mg – 1 cap oral qday
Side effects
1.Edema
2.Acute renal failure
3.Nocturia
Pharmacological class: calcium channel blocker
oDipyridamole/Asprin – Aggrenox
1 cap oral BID
Side effects
1.Headaches
2.Bronchospasm
3.Bleeding risk
Pharmacological class: antiplatelet
oAscorbic Acid – Vitamin C
1000 mg – 2 tab oral qday
Side effects
1.Headaches
2.Nausea
3.polyuria
Pharmacological class: water-soluble vitamin o Lisinopril – Zestril
 10 mg – 1 tab oral qday
 Side effects
1. Vertigo
2. Renal insufficiency
3. Angioedema
 Pharmacological class: ACE
o Vitamin E
 1000 mg – 1 cap q day
 Side effects
1. Headaches
2. Increased risk for thrombophlebitis
3. Weakness
 Pharmacological class: Fat-soluble vitamin
o Meropenem – Merrem
 500 mg – 1 vial IVPB
 Side effects
1. Seizure
2. Headache
3. Pulmonary embolism
 Pharmacological class: Anti-infective
o Erythromycin
 333 mg – 1 tab oral TID
 Side effects
1. Seizures
2. Dysrhythmias
3. Hepatotoxicity
 Pharmacological class: Macrolide o Famotidine – Pepcid
 20 mg/2ml IV-Push q12h
 Side effects
1. Dysrhythmias
2. Thrombocytopenia
3. Pneumonia
 Pharmacological class: H-2 histamine receptor antagonist
o Flagyl
 500 mg – 1 tab oral TID
 Side effects
1. Seizures
2. Nephrotoxicity
3. Bone marrow depression
 Pharmacological class: anti-infective
PRN Medications
o Tylenol
 500 mg – 1 tab q4HP
 Side effects:
1. Hepatotoxicity
2. GI bleeding
3. Renal failure
 Pharmacological class: nonopioid analgesic
o Nitrostat
 0.40 mg – 1 tab subling PRN
 Side effects
1. Headache
2. Hypotension
3. Flushing
 Pharmacological class: Nitrate
o Zofran
 4 mg/2ml – IV-push q4HP
 Side effects
1. Headache
2. Constipation
3. Fatigue
 Pharmacological class: 5-HT receptor antagonist Physical Assessment Vital Signs
o TPR = 102 oral
o BP = 140/76
o O2 Sat = 100% on 4L NC
o RR= 19
o HR=77
• Lab Values
o Lab's/Test's/Procedures: Gluc=220 High, HGB=9.6 Low, HCT=30.8 Low, RBC 3.76 Low
• Diagnostic Test
o Cardiac Catherization is pending due to patient having a temperature
 Patient being tested for sepsis – test results pending at end of my shift
• Physical Assessment
o Safety- Pt. appears to be stable and consistently up without assistance. Monitor for changes due to effects of medication. Patient is not a fall risk at this time. Pt. is currently using urinal due to being on oxygen.
o Neuro/Musculoskeletal – Pt. is oriented to person, place and year. No difficulties swallowing. Patient wears corrective lenses. No hearing aids or dentures. Patient follows commands and speach is clear. Patient maintains eye contact when speaking. No hx of falls.
o Respiratory – Pt. is currently on 4 Liters of oxygen. Pt.’s O2 stats remain at 100% throughout my shift even while moving/change positions. Lungs are clear throughout. Easy respirations and equal expansion. Patient states he has no difficulty breathing at this time. Patients respirations at 19
o Cardiovascular – Patient is currently in sinus rhythm and at a regular rate. Patient’s blood pressure was 140/76, HR of 77. No edema and capillary refill < 3 seconds. Radial and dorsal pedal pulses equal and strong bilaterally.
o GU/GI/Skin: Patient currently using a urinal to void due to use of oxygen. Urine is clear and yellow with no odor. Patients last BM on 3/11 prior to. ED. BM had blood in it. Patient currently on a restricted carb diet. No restraints or TED/SEQ in place. Patient’s skin is elastic and dry. No skin integrities.
• Potential harms or hazards that relate the patient’s primary dx or the past medical hx.
o Patient has a family history of heart disease
o Patient has a hx of hyperlipidemia
o Diabetes – restricted carb diet Nursing Diagnosis #1 Decreased cardiac output r/t altered electrical conduction aeb patient states SOB (dyspnea). Nursing DX #1 Rationale Dx chosen due to pt. being in atrial fibrillation, Maslow's Hierarchy of needs (Physiological= breathing and homeostasis), ABC's (Airway, Breathing and circulation all affected by dx). STG Patient will demonstrate adequate CO aeb BP, & rhythm within normal limits for patient by end of clinical day S/S of dyspnea: sob, air hungry, chest tightness, labored breathing, O2 stats lower than 95% LTG Patient will explain actions and precautions to take for primary or secondary prevention of cardiac disease before discharge from the unit BP (SBP <150, >100, DBP >70, <90), CO (resting CO 5.6 L/min),Urinary Out (>500 ml, < 2.5 L 24 hr ), strong peripheral pulses WNL Intervention #1:
The nurse will observe pt. for restlessness, agitation, & confusion q 4 hours. Rationale #1: Changes in behavior & mental status can be signs of impaired gas exchange which will result from decreased cardiac output Intervention #2:
The nurse will administer oxygen per order. 4 liters NC per physician orders Rationale #2: supplemental oxygen increases oxygen
availability to the myocardium Intervention #3:
The nurse will access pt. for chest pain or discomfort noting
location, severity, duration,
quality & radiation Rationale #3: Chest pain generally indicates
inadequate blood supple to the heart Invention #4: The nurse will assess pt. for pulmonary
embolism Rational #4: Thrombi can form in R atrium
with A-fib and move to the lungs (Workman p. 745) s/s: SOB, chest pain,
blood-tinged sputum
& feelings of impending
doom. Intervention # 5: The nurse will administer Cardizem
120 mg 1 tab qday Monitor HR & BP Teach pt. to report dyspnea, orthopnea, distended neck veins, or swelling of extremities. side effects Intervention #6:
Monitor hourly urine
output Rationale #6: Decreased CO results in decreased
perfusion to the kidneys leading to decreased
urine output. Urine output
should be > 30 ml/h Check BP, Pulse before giving medication
notify physician if BP & HR are low (Ackley & Ladwig, 2011) Intervention #1 (LTG): The nurse will discuss modifiable and non-modifiable risk factors.
Modifiable: Situations pt. can change such
as; physical inactivity, dietary habits, tobacco use,
alcohol abuse, high BP, high fat intake, high blood lipids, high blood glucose, stress. Intervention # 2 (LTG): The nurse will teach pt. non-pharmacological
methods
of reducing stress Meditation Coping skills
used in past that were
effective Rational # 5: This medication
helps with a-fib. Rational #1: Pt. needs to have the
knowledge to know what he can do to
change this disease process. Rational # 2: Reducing stress
reduces work load on the heart. Intervention # 3 (LTG): The nurse will provide a restful environment by minimizing controllable stressors and unnecessary disturbances (Ackley, 2011). Rationale # 3: Rest helps lower arterial
pressure Intervention #4: The nurse will arrange for a dietician to teach pt. about small, frequent, sodium-restricted, low-cholesterol meals (Ackley, 2011). Rational # 4: Small meals require less cardiac output to digest (Ackley, 2011). Fresh fruit, fresh vegetables or steamed
vegetables, grilled meats
such as chicken and fish Nursing Diagnosis #2 Deficient Knowledge r/t lack of exposure aeb patient inability to state reason for new cardiac medication. Rational of STG: Pt. currently
has limited knowledge of new
medications. Rational: Cardiac issues can
be life threatening and
understanding of medication
is important for adherence to
treatment regiment. STG: Patient will explain action of new cardiac medication by the end of the clinical day LTG: Patient will
recognize the medication
and state when medication
should be taken by discharge from
the unit. Intervention #1 STG: The nurse will consider the patients ability and readiness to learn. Rational#1 STG: Pt.'s readiness to learn
will determine how much he will retain. His readiness
will change depending on how he is feeling. Intervention #2 STG: The nurse will assess personal context and meaning of illness to patient. Rational #2 STG: Interventions that focus on
needs of the patient will improve patient management of medication. Perceived change in lifestyle & financial concerns access pain level, motivation and emotional
readiness Intervention #3 STG: The nurse will assess the client's literacy skill when using written information. Rational #3: Nurse may over estimate
reading and comprehension level of the pt. Intervention #4 STG: The nurse will provide both written and verbal information regarding new medication education. Rational #4: Both written and verbal
information have been proven effective
methods to enhance pt. knowledge. Intervention #1 LTG: The nurse will provide visual aids to enhance learning. Rational #1: Pictures are simple
and easy to follow. Also helpful when trying
to visually identify a medication. Intervention #2 LTG: The nurse will use problem-solving education to teach the patient. Rational #2: This method of teaching
has been proven more effective (Ackley, 2011). Ask patient to identify medication
during administration and make it the patients
responsibility to notify the nurse at time mediation is
to be given (with-in limits, nurse would not allow too much time to pass before giving medications without patient notification). Intervention #3 LTG: The nurse would use computer and web-based methods as appropriate. Rational #3: The patient would have access
to these teaching methods after
discharge from the unit. Intervention #4 LTG: Use teaching methods that reinforce learning an allow adequate time for mastery the content. Rational #4: Teaching strategies that focus on repetition and simple content are easier to retain. Nursing Diagnosis #3 Bleeding r/t colon mass aeb visible blood loss. Nursing DX #3 Rationale Dx chosen due to pt. being presenting to the ED with rectal bleeding, Maslow's Hierarchy of needs (Physiological= blood loss and imbalanced homeostasis), ABC's (Airway, Breathing and circulation all affected by dx). STG: Maintain stable vital
signs with minimal blood loss by end of clinical day LTG: Explain actions to take if bleeding occurs Rational: Stable VS and minimal
blood loss are vital to maintain homeostasis Pt. education is an important part of
maintaining life Intervention #1 STG: The nurse will assist the pt. in meeting the needs of defecation Rational #1: defecation can occur
suddenly without warning Place necessary supplies near bed, pull
curtain and immediately dispose of feces Intervention #2 STG: Increase and maintain oral fluid intake. 2 liters in 24 hour period Rational #2: Prevents dehydration Intervention #3 STG: The nurse will observe and record the frequency of defecation, stool volume and characteristics. Rational #3: Assessing the development of an issue and amount of blood loss Intervention #1 LTG: The nurse will educate the patient on signs of perforation and peritonitis. observe for fever, heart palpitations (tachycardia),
lethargy, anxiety. Seek emergency attention. Rational #1: anticipating the danger signs of perforation
and peritonitis requiring emergency action. Printed material of what medication/pills
look like. Will also show and let patient hold
and inspect medication before administering. Intervention: The nurse will discuss the characteristics of blood in the stool. Moderate to light amounts bright red blood
may be an indication of hemorrhoids and/or constipation/hard stool passing Coffee ground like stool indicates bleeding more
severe type of internal bleeding. Rational #2: Its important to distinguish between
the two Intervention #3 LTG: Nurse will educate patient if has a large amount of blood in stool to seek medical attention immediately. Rational #3: Large amounts of
blood loss can lead to a life
threatening situation Intervention #4 STG: The nurse will continuously monitor pt.'s VS to access/adjust intervention to help VS remain stable. Rational# 4: Blood loss can affect
VS Evaluation All goals met other than pt. being able to recognize and state reason and time for new cardiac medication. More time is needed for this patient to accomplish this goal. Rectal bleeding is also known as hematochezia. Rectal bleeding refers to the passage of red blood cells from the anus. The blood is often mixed with stool and/or blood clots. Goal met. Pt. in sinus rhythm by end of clinical shift Goal met pt. was
able to verbalize understanding
of precautions to take by end of clinical day Evaluation: Goal not met. More
time needed. Evaluation: Goal not obtained by end of
clinical day. High glucose= poor diabetes management or sometimes an additional illness can cause increased levels.
HGB, HCT, RBC = due from blood loss or dehydration
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