Mr. Theodore Jeffers is a 73-year-old admitted to the progressive coronary care unit with a diagnosis of atypical chest pain and congestive heart failure. He has a history of acute myocardial infarction, deep vein thrombosis, hypertension, diabetes mellitus, and gouty arthritis. He reports "spasm-like" chest pain over his breastbone and difficulty "catching my breath." His admission data includes the following:
• Chest pain rated as a 4 on a scale of 1 to 10; states,"It feels like my heart is clenching like a fist—I am notsure I can call it pain."
• BP: 172/100 – 102 – 30
• Temperature: 99.2°F
• O2 saturation: 90% on room air
• Lungs: fine crackles throughout all lung field
s• Heart sounds with S3 present
• 4+ pitting edema, decreased peripheral pulses bilaterally,feet cool to touch
• Height: 72 inches; Weight: 231#; BMI: 31.3
1. a. Mr. Jeffers is placed on continuous cardiac monitoring. As the primary nurse, what are your responsibilities in the care of a patient requiring this type of monitoring?
b. For the patient with cardiac dysrhythmias, what is the nursing diagnosis that drives the prioritization of care? Is this the correct diagnosis for this patient? Why or why not?
c. The NOC outcome that is determined for Mr. Jeffers is cardiac pump effectiveness. Based on Mr. Jeffers’s status, write four individualized expected outcomes that will demonstrate resolution of the diagnosis.
d. Mr. Jeffers tells you during the morning assessment, "I know I have had this happen before but I think I just might die this time around." How should you respond to this statement?314 Unit 4 | Supporting Physiological Functioning.
e. As the day progresses, Mr. Jeffers becomes confused. Based on your understanding of oxygenation and perfusion, what is the probable etiology of this change in status?
f. Mr. Jeffers is a "full code." If he should need resuscitation, can you legally and ethically delegate basic cardiopulmonary resuscitation (CPR) to unlicensed assistive personnel within the hospital setting? Give a rationale for your response.
a. The primary nurse's responsibilities in the care of a patient requiring continuous cardiac monitoring include assessing and analyzing the patient's cardiac rhythm, identifying dysrhythmias or changes in the rhythm, initiating appropriate interventions when necessary, and documenting the findings and interventions. They also need to ensure that the cardiac monitor is functioning properly, maintain the integrity of the leads and electrodes, and communicate any changes or abnormalities to the healthcare team.
b. The nursing diagnosis that drives the prioritization of care for a patient with cardiac dysrhythmias is "Decreased Cardiac Output." This diagnosis relates to the inadequate pumping of blood by the heart, leading to decreased systemic perfusion. In this case, it is the correct diagnosis for Mr. Jeffers as he has signs and symptoms of congestive heart failure, including decreased peripheral pulses, pitting edema, lung crackles, and an S3 heart sound.
c. - Mr. Jeffers will have a normal heart rate and rhythm within the expected range by the end of the shift.
- Mr. Jeffers will demonstrate improved oxygen saturation levels above 95% on room air within 24 hours.
- Mr. Jeffers will have decreased peripheral edema in lower extremities, with 2+ pitting within 48 hours.
- Mr. Jeffers will report improvement in breathing and chest discomfort, rating it as less than 3 on a scale of 1 to 10, within 12 hours.
d. The appropriate response to Mr. Jeffers' statement would be to provide reassurance and support. The nurse can say, "I understand that this can be a scary experience for you. We are here to take care of you and will do everything we can to help you feel better. Let's work together to manage your symptoms and improve your condition."
e. The probable etiology of the change in Mr. Jeffers' mental status from confusion could be inadequate perfusion to the brain due to decreased cardiac output. The decreased systemic perfusion caused by congestive heart failure can lead to reduced oxygen and nutrient supply to the brain, resulting in confusion and altered mental status.
f. No, it would not be legally or ethically appropriate to delegate basic CPR to unlicensed assistive personnel (UAP) within the hospital setting. Basic CPR requires advanced training and expertise in cardiac arrest management and resuscitation techniques. Only licensed healthcare professionals, such as registered nurses or doctors, should perform basic CPR to ensure the safety and well-being of the patient.
a. As the primary nurse, your responsibilities in the care of a patient requiring continuous cardiac monitoring include:
- Ensuring that the patient is connected to the cardiac monitor at all times, which usually involves attaching electrodes to the patient's chest.
- Monitoring the patient's heart rate, rhythm, and any changes or abnormalities in the EKG waveform displayed on the monitor.
- Recognizing and interpreting any dysrhythmias or changes in the EKG, and notifying the healthcare provider of any significant findings.
- Responding promptly to any alarms or alerts from the cardiac monitor.
- Assessing the patient's vital signs and symptoms regularly and comparing them with the displayed EKG to identify any correlation.
- Administering prescribed medications or interventions as needed, such as antiarrhythmics or cardioversion.
- Providing education and support to the patient and their family regarding the purpose and importance of cardiac monitoring and what to expect during the monitoring period.
b. The nursing diagnosis that drives the prioritization of care for a patient with cardiac dysrhythmias is "Decreased Cardiac Output." This diagnosis is based on the understanding that dysrhythmias can impair the heart's ability to effectively pump blood, leading to inadequate tissue perfusion and oxygenation.
For Mr. Jeffers, the correct nursing diagnosis would be "Decreased Cardiac Output" as he has congestive heart failure, which impairs the heart's ability to effectively pump blood. This is evident from his symptoms of chest pain, difficulty breathing, lungs with fine crackles, presence of S3 heart sound, and peripheral edema.
c. For Mr. Jeffers, the individualized expected outcomes that will demonstrate resolution of the "Decreased Cardiac Output" nursing diagnosis could include the following:
1. Increase in oxygen saturation level to above 95% on room air.
2. Reduction in chest pain intensity to a score of 2 or lower on a scale of 1 to 10.
3. Improvement in peripheral pulses bilaterally, with no signs of peripheral edema.
4. Absence of fine crackles in lung fields during auscultation.
d. In response to Mr. Jeffers's statement of feeling like he might die this time around, it is important to provide empathetic and supportive care. You can respond by acknowledging his feelings and expressing your dedication to providing the best care possible. For example, you could say, "I understand that you may be feeling scared or worried, but please know that we are here to take care of you. Our team is committed to doing everything we can to help you recover and get through this."
e. The probable etiology of Mr. Jeffers becoming confused as the day progresses could be related to inadequate oxygenation and perfusion to the brain. This can be caused by the decreased cardiac output resulting from his congestive heart failure, which leads to insufficient blood flow to the brain. Decreased oxygen and nutrient supply to the brain can result in cognitive impairment, confusion, and altered mental status.
f. The delegation of basic cardiopulmonary resuscitation (CPR) to unlicensed assistive personnel (UAP) within the hospital setting depends on legal and institutional policies. In many cases, basic CPR can be delegated to trained UAP under the direct supervision of a licensed healthcare professional. However, it is essential to consider the specific policies of the hospital and any legal requirements or restrictions that may apply.
The rationale for delegating CPR to UAP can be based on increasing the availability of trained personnel who can promptly respond to cardiac arrest situations. However, it is crucial to ensure that the UAP has completed appropriate CPR training and that their competency is regularly assessed to maintain the safety and effectiveness of their interventions.