Mrs. Brown, an 80 year old female was admitted into the coronary care unit two days after having cardiac surgery to replace her aortic valve with a porcine valve. Mrs. Brown is overweight and has a history of coronary artery disease, hypertension, CHF and chronic bronchitis. At 0800 her vital signs were BP 110/70, T 36.6, P 70, R 18 and SpO2 92% on nasal cannula at 2LPM. Her lungs were clear and she had 3+ pedal and tibial edema. At 0900 h she calls for help as she had to use the washroom badly, it was noted on her incontinent product that there was a large amount of loose red stool. She was diaphoretic, restless and anxious and there was an audible wheeze in her lungs. Her vitals changed to BP 92/65, T 36.6, P 110, R 30 and SpO2 at 89% on 2LPM. In this paper, I will be preparing a nursing care plan for Mrs. Brown including 5 nursing diagnoses, I will organize the 3 most important diagnoses according to prioritization with rationale. For the most important diagnoses I will be including the assessment data that is provided in the case study that supports my diagnoses along with 3 nursing interventions to help Mrs. Brown. “Individualized care plans are tailored to meet the unique needs of a specific clientâ€¦when nurses use the client’s nursing diagnoses to develop goals and nursing interventions, the result is a holistic, individualized plan of care that will best meet the client’s unique needs” (Kozier et al., 2010, p. 440).
Identification of Postoperative Patient Problems
1. Impaired gas exchange related to pulmonary congestions as evidenced by audible wheeze, declining hemoglobin, decreasing oxygen saturation, rapid respirations and rapid pulse.
2. Ineffective tissue perfusion (cardio pulmonary) related to deceasing blood volume as evidenced by hypotension, increasing pulse, decreasing haemoglobin, rapid respirations and diaphoresis.
3. Deficient fluid volume related to dropping blood pressure as evidenced by incontinent product soiled with large amount of loose red stool.
4. At risk for infection related to cardiac surgery.
5. Risk for injury related to unsteady gate.
First Postoperative Patient Problem
Ineffective tissue perfusion (cardio pulmonary) related to decreased blood volume as evidenced by hypotension, increasing pulse, decreasing haemoglobin, rapid respirations and diaphoresis.
This is the most important problem because I believe Mrs. Brown may be experiencing shock. “Shock is a syndrome characterized by inadequate tissue perfusion resulting in impaired cellular metabolism. Inadequate tissue perfusion deprives cells of essential oxygen and nutrients, and subsequent organ failure may happen” (Linton, 2012. p. 309). Mrs. Brown is on medications that thin her blood such as aspirin and warfarin those combined with amindodarone can cause a serious and life threatening complications of bleeding (Medication Interactions, 2012. para 1). Judging from her PTT, INR and low platelet levels she is in extremely high risk; her blood is so thin that a small cut could cause her to bleed out. Guessing from how normal her blood pressure was an hour ago and how fast it has declined, I believe she is bleeding out in her intestines or bowels (also judging from her loose red stool). “The primary nursing diagnosis for all patients in shock is Altered Tissue Perfusion” (Linton, 2012, p. 317). With hypovolemic shock you are loosing fluid (blood) faster then your body can handle, with loss of fluid you have poor tissue perfusion. I believe she is on the higher end of compensatory stage but getting closer to decompensated or progressive stage of shock. One main determinant of progressive stage is hypotension which is a hallmark sign indicating the change from compensated to decompensated stage (Linton, 2012. p. 312). Without adequate oxygen and nutrients to cells, death can soon follow.
Second Postoperative Patient Problem
Deficient Fluid Volume related to dropping blood pressure as evidenced by large amount of loose red stool.
The red stool is telling us that she is bleeding in the lower portions of her bowels because it is bright red. From seeing her PTT, INR and platelet count, the bleed is probably not going to stop anytime soon. She is lacking clotting factors, and because of that this bleed is not going to stop and her blood volume is only going to keep dropping, therefore her blood pressure will keep declining. “Hypovolemia with impaired circulation and cellular dehydration may cause decreased function in all tissues and organs” (Dyer & Gould, 2011. p. 388). Blood volume will need to be fixed first before the oxygen can get into the tissues, which is why deficient fluid volume is my second postoperative problem. “If shock is prolonged, cell metabolism is diminished, and cell wastes are not removed, leading to acidosis, which impairs cell enzyme function. Acidosis also tends to cause vasodilatation and relaxes precapillary sphincters first, contributing further to the pooling of blood in the periphery and decreasing venous return to the heart” (Dyer & Gould, 2011. p. 316).
Third Postoperative Patient Problem
Impaired gas exchange related to pulmonary congestion as evidenced by audible wheeze, decreased haemoglobin, declining oxygen saturation and rapid respirations.
Adequate gas exchange is vital for keeping organs alive. We can tell she is not receiving enough oxygen from seeing her SpO2 levels dropping, her heart rate and respirations are increasing because her heart and lungs are trying to get more oxygen in the blood. Haemoglobin levels are dropping and are getting close to the danger zone of needing a blood transfusion and we can hear wheezing upon listening to her lungs. These signs and symptoms are all pointing to inadequate gas exchange. “With chronic bronchitis, mucus obstructs the airway, causing air to be trapped in distal portions of the lungs. Alveolar ventilation is impaired, and hypoxemia may develop” (Linton, 2012. p. 586). Her hematocrit levels are higher then normal but that could have to do with the chronic bronchitis; “with chronic hypoxemia, the RBC count is typically elevated to compensate for inadequate PaO2” (Linton, 2012. p. 587). Mrs. Brown’s veins are constricting because her body is trying to keep her blood circulating, “vasoconstriction reduces arterial blood flow into the tissues and organs, causing ischemia and eventually necrosis” (Gould & Dyer, 2011. p. 316). Impaired gas exchange is my third postoperative problem because you need to have adequate blood volume and perfusion of the tissues first so oxygenation of tissues can take place.
Detailed Post Operative Assessment of Chosen Issue
Signs and Symptoms that Mrs. Brown is suffering from ineffective tissue perfusion are as follows: her blood pressure has dropped to 92/65 because of dropping fluid volume, her pulse is at 110 because her heart is compensating trying to get more oxygen into the tissues and keep the remaining blood she has circulating. Respirations are at 30 because her lungs are trying to bring more oxygen into the body. SpO2 levels are dropping partly because the doctors orders are not being followed of administering 6L of oxygen, they are only giving her 2L but also because of her rapidly declining haemoglobin so oxygen cannot enter the tissues. Her restlessness, diaphoresis and anxiousness are all compensations of the sympathetic nervous system to maintain heart and brain functions. The reason she is suffering from shock is because she is more then likely bleeding out. The combination of aspirin, warfarin and amiodarone leads to an extremely high risk bleeding complications. The furosemide and enalapril that she is receiving daily is more then likely not helping her situation at this point in time either with a dieuretic (lowering her fluid volume) and ACE inhibitor (lowering her blood pressure) making this situation even worse. Her creatinine levels are increased I believe because she may be experiencing pre kidney failure. Her blood is diverting away from kidneys in hopes of protecting the heart and brain through a sympathetic nervous system response. If the problem is not corrected and kidneys don’t receive adequate blood supply, permanent damage and ischemia will occur. I am expecting after the Doctor is notified, to administer a bolus of normal saline or ringers lactate and possibly administer vitamin K as it is a warfarin antidote. After calling for help but before the Doctor gives me medication orders my nursing interventions are as follows:
Nursing Intervention #1:
Lay Mrs. Brown flat in her bed and elevate the legs.
Rationale: Elevating the legs will help keep the blood supply in her major organs.
Nursing Intervention #2:
Administer 100% oxygen through a rebreather mask.
Rationale: Administering oxygen will increase the amount of oxygen in their blood, allowing tissues to be perfused. The rebreather mask is important because it allows the patient to rebreathe CO2 which acts to stimulate breathing.
Nursing Intervention #3:
Ensure Mrs. Browns ABC’s (airway, breathing and circulation) are maintained and check vitals at least every 15min.
Rationale: These are important vitals and if one of the ABC’s failed, CPR would be implemented. Keeping an eye on her vitals allows you to somewhat judge what is going on internally and able to see if her condition is deteriorating.
In order for Mrs. Brown to get better, we need to stop the bleeding. Administering the vitamin K I believe would be a key intervention that needs to be initiated from the Doctor. Also administering saline bolus to increase her fluid volume is key so more oxygen could get to her tissues. Without an intervention of increasing her fluid volume or vitamin K, her situation will become more bleak and likely enter the irreversible (refractory) stage of shock and death may ensue. In conclusion, I believe this whole situation could have easily been avoided. Knowing that amiodarone reacts with warfarin the way it does I believe the Doctor and or nurse would not have administered her medications. Even without knowing how those medications mix, if the nurse would have looked at Mrs. Brown’s lab values, specifically PTT and INR prior to administering the medications this emergency situation would have been prevented.
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