In the nursing process, a critical part entails a nursing diagnosis that gives an insight about the modalities to enable quick patient recovery amidst actual or probable health interventions. Each procedure in the diagnosis plan has some outcomes which if achieved, are a clear demonstration of a successful process. In essence, the overall nursing process entails several definitive procedures which are interdependent though work objectively to a common goal. The first step involves assessment, followed by diagnosis which is either actual or risk in nature, planning for treatment, implementation which is the real treatment, and the last step is evaluation to determine success or failure. In heart attack situations, the same procedures follow. There is actual diagnosis as well as ‘risk for’ procedures.
Actual Diagnosis-A critical judgment of the Patient’s Responses to Health Conditions
Nursing Diagnosis 1: Impaired gas exchange
It can be a sign of chronic bronchitis as well, and it is related to ventilation-perfusion imbalance. In most occasions, the patient complains of a headache upon awakening, and is hypoxic, while the O2 is 88%. Other signs include irritability and restlessness.
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Case reflection: In ordinary circumstances, diffusion enables gas exchange to take place between the alveoli and the pulmonary capillaries. Oxygen-carbon dioxide diffusion often happens passively in relation to their levels of concentration crosswise the alveolar-capillary barrier. In cardiac concentration levels maintenance, these levels must be kept at balance by ventilation and enabling air flow between the alveoli and the pulmonary capillaries. If it doesn’t happen, heart attack is highly possible.
Gas exchange problems also emanate from the conditions that cause undesired changes or collapse the alveoli thereby impairing ventilation. These cases include pneumonia, pulmonary edema, and in other situations acute respiratory distress syndrome (Mallick, 2008). Other factors include high altitudes which might affect oxygen-carrying capacity of the blood due to low levels of hemoglobin thereby affecting gaseous exchange as well.
Goals: The patient will clear lung fields and remain free of evidence of respiratory distress during the period at the hospital. Secondly, she should be able to exhibit improved ventilation and adequate oxygenation as demonstrated by blood gas levels within normal parameters, and maintaining 95% oxygen saturation before the end of the shift. Thirdly, before 8 hours of nursing interventions expire, the patient will actively take part in treatment regimen within level of ability and situation.
Nursing Interventions: The registered nurse will monitor oxygen saturation continuously using pulse oximetry and note blood gas results as available, and use non-rebreather to increase the oxygen rate. The RN will also monitor respiratory rate, depth, and ease of respiration, and watch for the use of accessory muscles and nasal flaring throughout the shift. Moreover, the registered nurse will calculate breath sounds every 1 to 2 hours. The presence of crackles and wheezes may alert the nurse of airway obstruction.
Rationale for interventions
An oxygen saturation of less than 88% (normal: 95% to 100%) or a partial pressure of oxygen of less than 55 mm Hg (normal: 80 to 100 mm Hg) indicates significant oxygenation problems. Pulse oximetry is useful for tracking and/or adjusting supplemental oxygen therapy for clients with COPD ( GOLD, 2015 ). Secondly, normal respiratory rate should be 14 to 20 breaths per minute in an adult ( Bickley &Szilagyi, 2012 ). Thirdly, in severe exacerbations of chronic obstructive pulmonary disease (COPD), lung sounds may be diminished or distant with air trapping ( Bickley &Szilagyi, 2012 ).
Collaborative Interventions
The first intervention involves the administration of supplements: Administer supplemental oxygen judiciously via nasal cannula at 2L/min. The other has to do with administering medications as recommend: Pulmodual 5-6 drops Q6H RTC. Thirdly, although it may appear in a way as a nursing independent intervention, it is important to evaluate sleep patterns, note reports of difficulties and whether client feels well rested. On the same case, provide quiet environment and group care and monitoring activities to allow periods of uninterrupted sleep. Also, limited stimulants such as caffeine are necessary while encouraging position of comfort at all times.
Note of purpose: the critical interventions for nurses include regularly assessing respiratory rate and depth, noting the use of accessory muscles, pursed-lip breathing, and inability to speak or converse. Also, as a very critical role player in the patient’s recovery process, it is essential for the RN to keep elevating head of bed and assist the patient to assume comfortable positions to ease work of breathing. Above all, a nurse should include periods of time in prone position as recommended. As RN as well, encourage deep, slow or pursed lip breathing as individually needed and tolerated (Mallick, 2008).
Nursing Diagnosis 2: Decreased cardiac output
It is an effect of altered heart rhythm. Causative factors include Myocardial infarction or ischemia, valvular disease, cardiomyopathy, and serious dysrhythmia. Also, ventricular damage, altered preload or afterload, pericarditis, and sepsis have a high probability of causing a decreased cardiac output.
In nursing, the outcomes conclude the patient demonstrating adequate cardiac output as evidenced by blood pressure, pulse rate and rhythm within standard parameters before discharge. Secondly, the patient has no chest discomfort, and ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain before the end of the shift. Thirdly, the patient remains free of side effects from the medications used to achieve adequate cardiac output.
Nursing interventions: These involve cardiac care and circulatory care. The registered nurse (RN) will recognize primary characteristics of decreased cardiac output as fatigue, edema, and dyspnea before the end of the shift. Secondly, the RN will monitor orthostatic blood pressures and daily weights every shift. Thirdly, the RN will watch laboratory data carefully, especially arterial blood gasses, CBC, electrolytes including sodium, potassium, and magnesium, and B-type natriuretic peptide every shift. Moreover, the RN should monitor for symptoms of heart failure and decreased cardiac output, including diminished quality of peripheral pulses, cool skin and extremities, increased respiratory rate, presence of paroxysmal nocturnal dyspnea or orthopnea, increased heart rate, neck vein distention, decreased level of consciousness, and presence of edema. As these symptoms of heart failure progress, cardiac output declines.
Rationale: The nursing diagnosis decreased cardiac output in a clinical environment identified and categorized related client characteristics that were present as primary or secondary. On the other hand, assessing chest pain, monitoring respiratory rate, depth, and its ease assess for fluid volume in the body status (Carpenito-Moyet, 2006). The extent of volume overload is highly essential to deciding on appropriate treatment for HF. Thirdly, routine blood work can provide insight into the etiology of HF and extent of decompensation.
Collaborative interventions: Most of the effective approaches involve practices outside the hospital environment. Firstly, the RN should begin discharge planning as soon as possible with case manager or social worker to assess home support systems and the need for community or home health services. These may be to assist with home care, assistance with meal preparations, housekeeping, personal care, transportation to doctor visits, or emotional support. Clients often need help upon discharge. The existing social support network needs to be assessed and assistance provided as needed to meet client needs and to keep the support persons from being overwhelmed. Being discharged to home without adequate support has been shown to be related to readmission of elderly patients.
Secondly, continue to monitor client for exacerbation of heart failure when discharged home. Transition to home can create increased stress and physiological instability related to diagnosis. On the same case, devise an emergency plan, including use of CPR. Decreased cardiac output can be life threatening.
Thirdly, instruct family and client about the disease process, complications of disease process, information on medications, need for weighing daily, and when it is appropriate to call doctor. Early recognition of symptoms facilitates early problem solving and prompt treatment. Clients with heart failure need intensive guideline based education about these topics to help prevent readmission to the hospital.
Nursing Essentials: It is necessary during acute events to ensure client remains on bed rest or maintains activity level that does not compromise cardiac output. In severe heart failure, however, restriction of activity often facilitates temporary recompensation (Carpenito-Moyet, 2006). On the same case, the RN should gradually increase activity when client's condition is stabilized by encouraging slower paced activities or shorter periods of activity with frequent rest periods following exercise prescription; observe for symptoms of intolerance. Above all, take blood pressure and pulse before and after activity and note changes factoring that activity of the cardiac client should be closely monitored at all times.
Risk Diagnosis: ‘Risk for’ Depression
Depression stems from the patient’s inability towards self-care and those that he/she is supposed to serve.
Outcomes: The patient will identify and verbalize symptoms of the situation before the end of the assessment period. Secondly, the patient will manage posture, facial expressions, gestures, and activity levels that reflect decreased distress after 4 hours. Thirdly, the patient will show positive responses and ability to manage situations that can cause distress.
Nursing interventions: The RN will assess the patient’s level of depression and physical reactions to the concern. Symptoms evaluated are mood, tension, fear, insomnia, concentration, worry, depressed mood, somatic complaints, and cardiovascular, respiratory, gastrointestinal, genitourinary, autonomic, and behavioral symptoms. Secondly, the RN will explain all activities, procedures, and issues that involve the client’s condition; the RN will use nonmedical terms and calm, slow speech in advance of methods and validate the patient's understanding in every assessment period. Thirdly, the RN will use therapeutic touch, healing touch techniques and use empathy to encourage the client to interpret the depression symptoms as normal before they part.
Collaborative Interventions: Several collaborative interventions drive the desired outcomes when dealing with the risk of depression scenarios. The first intervention includes targeted skill improvement. It has entirely to do with the identification of staff that may benefit from coaching on accurate use of the Patient depression screeners. Secondly, there is a “warm hand-off” from the primary healthcare providers (PCP) to the depression clinician, which ensures early patient engagement in treatment. The warm hand-off provides an opportunity to introduce the program to the patient in person, to set a behavioral activation goal, and to demonstrate the collaboration between PCP and collaborative care team members. Thirdly, there is the use of the depression registry to manage the stepped-care approach, such as psychiatric consultation or a change in clinical intervention for enrolled patients who are not improving in any way.
Heart Failure: Patient Handling, Testing and Collaborative Care
Handling patients with heart problems is quite complex, and the registered nurses (RN) responsible need to have detailed knowledge about the disease and cause agents as well as understanding a victim’s concerns in an accurate manner. In diagnosis, several particular tests are vital for patients with signs and symptoms of heart failure. In the lab, a medical practitioner can carry out drug level tests, chemistry analysis, hematology or coagulation tests. In other cases, it is important to combine several or all for better results. In this case, the laboratory tests included glucose and platelets test. The latter is for patients who usually have an indication for high carbohydrate intake while the former is in situations where a patient has thrombocytopenia which leads to low platelet levels.
Another important examination includes sodium checks necessary when a patient receives a lot of fluids via intravenous. Other important tests include electrocardiogram and cardiac arrest test. On the same case, Chest X-ray is quite necessary if a patient complains of shortness of breath, chest pain, dyspnea and heart attack. If it happens to be the case, the RN gives pain medicine before the procedure, and helps in repositioning during the process and monitors the vital signs. After the procedure, the registered nurse makes sure that the patient is stable enough and does not complain of shortness of breath.
Far from that, it is essential to carry out aluminum tests for patients receiving a lot of fluids via intravenous as well as AST and ALT for liver damage checks. However, before immediate or advanced clinical testing, it is vital for the RN to investigate and analyze all the possible causes of a particular heart ailment to avoid haste decision making which can be negatively consequential if errors take place. Although independence during some diagnosis procedures is vital, it is crucial to embrace consultations when dealing with heart cases.
Collaborative Interventions in General
The success of the situation cannot come out as deserved without the effort of various members. It is a collaborative management where every member carries out a distinct function for the good of all. The different members included the physician, pharmacist, lab and diagnostic tests personnel, therapists, and the family. In effect, the role of the doctor remains paramount. In his absence, all the other functions are unnecessary. For instance, the physician examines the patient’s problem level and sets out the environment that follows. He is the one that advises on the kind of tests to take, and advises on the treatment location depending on the situation.
In like manner, the role of pharmacists and the lab personnel is crucial but depends on the registered nurses observations. The pharmacists could give drugs while advising on the alternatives if need be. On the other hand, the tests personnel prove vital since they give an accurate picture of the patient’s situation which helps the physician to make the final decision. Family, as a community is imperative considering that the recovery time of the patient also depends on the family efforts. They have crucial background information which as well can aid the nurses or other medical practitioner in examining and analyzing the causative factors which in some circumstances may not be entirely medical in nature.
References
Bickley,L.S., &.Szilagyi, P. (2012). Bate's Guide to physical examination . Internet Resource.
Carpenito-Moyet, L. J. (2006). Handbook of nursing diagnosis . Philadelphia: Lippincott Williams & Wilkins.
GOLD: Global strategy for the diagnosis, management, and prevention of COPD (2015). Global Initiative for Chronic Obstructive Lung Disease Retrieved April 23, 2015.
Mallick, S. (2008). Outcome of patients with idiopathic pulmonary fibrosis (IPF) ventilated in intensive care unit. Respiratory medicine , 102 (10), 1355-1359.
