NURS 479 Care Plan

Student: Lexi Heath Unit: Progressive Cardiac Care Unit Clinical Faculty:
Heidi Boddeker

Pt Initials: Age: 71 Gender: M. Code Status: Full Code

Allergies:__NKDA

SECTION ONE: Background

(10 POINTS)
Date: Reason patient came to ED or hospital and chief complaints:

October Initial reason the patient came to the hospital was due to constipation,
1 st weight gain, and abdominal distention. He was then given a diagnosis of
Metastatic Liver Cancer that has spread to the lymph nodes.

Date: Admitting Diagnosis:

October
20th
He was admitted to the Progressive Cardiac Care Unit due to his
unstable AFIB RVR.

Date: Why is your patient still hospitalized and what is the level of care
October (M/S, ICU, Rehab, etc.) ?
27th

He initially was brought to a Med-surg oncology floor but was

transferred to the Progressive Cardiac Care Unit due to his constant
 AFIB RVR. They also performed an echo that showed his Ejection
Fraction being 60-65%. They were also concerned about the possible
presence of DVT or PE but d-dimers came back negative. He also needed
better management controlling his HTN, DM, and performing a
paracentesis.

Date(s): List all important past medical and surgical history:

Some of his past medical history includes: Hyperlipidemia, HTN, Liver

Cirrhosis, previous smoker, Diabetes Mellitus Type 2, Left below the
knee amputation, AFIB, and sleep apnea. Within his stay at the hospital
he has recently had a right Portacatheter inserted for his chemotherapy.

SECTION TWO: Pathophysiology

Must use, and correctly cite, two timely and credible sources. One source must
be your pathophysiology, maternal health, or pediatric textbook..

(20 POINTS)
Disease Name: Atrial Fibrillation with Rapid Ventricular Response

1. What causes this condition?

Atrial Fibrillation is the most common arrhythmia and is typically seen within the
elderly population and complicates MI in 5-10% of cases (Capriotti, 2020). Some
causes of Atrial Fibrillation can include CAD, MI’s, Heart valve problems, HTN, lung
diseases, physical stress, sleep apnea, and even use of stimulants like tobacco.

2. What is happening at the tissue or cellular level to cause this problem?

“Atrial Fibrillation causes a quivering, non contracting atrium, leading to a

stagnation of arterial blood in the left atrium” (Capriotti, 2020). In this case the
patient is also experiencing rapid ventricular response (RVR) which means that the
P waves sent off stimulate this concomitant irregular, rapid ventricular response
(RVR).

3. What are the common s/s and clinical manifestations of this condition?
Underline the s/s that your patient has.

Some symptoms that may occur in a patient with Atrial Fibrillation include:
Irregular heart beat, heart palpitations, lightheadedness, extreme fatigue, SOB, and
chest pain.
 4. What are potential complications of this condition?

Some potential complications of Atrial Fibrillation can include the need to be

cardioverted. In this case it is very possible to dislodge a thromboembolism resulting
in a possible PE or Stroke (Jaakkola et al., 2018). Atrial fibrillation also goes hand in
hand with HF and can cause or be a consequence of reduced ejection fraction.

SECTION THREE: Diagnosis and Treatment

Must use and correctly cite two timely and credible sources. One source must
be your pathophysiology or lab textbook.

(25 POINTS)
1. Labs or tests used to diagnose this condition. Which ones did your
patient get and what were the results? List all abnormal results.

(Capriotti, 2020) & (Krishan & Mittal, 2021) & (Gruwez et al., 2021).

Lab Normal Value Patient Result

HGB 13.5-17.5 g/dL 8.9 g/dL

HCT 42-52% 38%

Magnesium 1.5-2.5 mg/dL 1.8 mg/dL

Potassium 3.5-5.1 mEq/L 4.6 mEq/L

INR nml 0.9-1.1 or std 2.6

therapy 2.0-3.0

PT 11-14 sec 17

aPTT 25-40 sec 38

 Test: Results:

EKG EKG showed irregularly irregular rhythm, no p

waves, absence of an isoelectric baseline, QRS
complex <120ms

D-Dimer <0.50 = Normal

Echo EF 60-65%

CT CT found metastatic liver cancer that was also in

the lymph nodes.

SECTION THREE: Diagnosis and Treatment (cont.)

 2. Expected treatments or medications – Current best practice according to
literature (cited). Is your patient receiving this treatment(s)? Include
medications.

Treatments:

One of the best things for a patient experiencing Atrial Fibrillation

treatment wise include cardioversion and catheter ablation with
supportive care of cardiac monitoring. My patient was on cardiac
monitoring or better known as telemetry. There are also surgery
options known as a cox maze procedure and mini maze
procedure. Those intolerant of anticoagulants can be offered an
effective treatment of left atrial appendage exclusion (Migdady et
al., 2021).

Medications:

Some medications for those experiencing Atrial Fibrillation

include direct-acting oral anticoagulants with a high BMI.
(Sebaaly & Kelley) My patient was being administered coumadin
 for this reason as well as prevention of possible PE and/or stroke.
Other medications that can be given include Beta blockers,
Calcium channel blockers, and antiarrhythmics. Specific to my
patient, one antiarrhythmic given was sotalol. An important thing
to remember about this drug after the first two administrations is
to get an EKG two hours afterwards to determine the efficacy and
effects of the medication.

SECTION FOUR: Plan of Care

(30 Points)
List Patient’s Top Five Priority Problems (in order of priority)

1. Patient is at risk for ineffective tissue perfusion.

 2. Patient is at risk for decreased cardiac output.

3. Patient is at risk for acute pain

4. Patient is at risk for activity intolerance.

5. Patient is at risk for increased fatigue.

Nursing Diagnosis for Problem # 1:

Patient has decreased cardiac output as related to atrial fibrillation as evidenced by

heart rhythm and overcompensated rate (160 bpm).

Measurable Goal for Problem # 1:

Patient will attain NSR within 2 days of care on the PCCU and maintain NSR
throughout hospital admission.

Priority Nursing Interventions to Meet Goal # 1:

Assess/Monitor Therapeutic

1. Ensure effective antiarrhythmic 1. Provide low stimulus environment

medication administration
2. Educate patient on deep breathing
2. Monitor patient on telemetry
3. Educate on heart healthy diet
3. Obtain EKG when necessary and
assess vitals 4. Educate on importance of active
moving
4. Monitor for symptoms of HF
5. Educate on signs and symptoms
 5. Assess patient’s LOC of HF

Nursing Diagnosis for Problem # 2:

Patient is at risk for ineffective cerebral tissue perfusion as related by Atrial

Fibrillation and disease process as evidenced by irregularly irregular rhythm,
increased fatigue, lower O2 saturations, and decreased CO.

Measurable Goal for Problem # 2:

Patient maintains effective tissue perfusion to vital organs as evidenced by LOC,

warm, pink, and dry skin, vitals within normal limits, and absence of heart
dysrhythmia.

Priority Nursing Interventions to Meet Goal # 2:

Assess/Monitor Therapeutic

1. Assess for decreased tissue

perfusion
6. Educate on the importance of a
2. Review lab values indicating heart healthy diet.
decreased tissue perfusion
7. Elevate HOB
3. Assess LOC or changes in mental
status 8. Keep low stimulus environment

4. Monitor intake and output 9. Assist with position changes

5. Administer NTG when 10.Help with active and/or passive

 experiencing complaints of angina ROM

SECTION FIVE: Integrative Therapy, Education, and Referrals

(10 Points)
Describe the Integrative Nursing Modality used on your patient and why this
therapy was selected:

This patient was given an explanation and demonstration for exercise and stress
relief. We felt this was most important considering his veteran history and PTSD as
well as his feelings of limitations regarding his L Below the knee amputation. We
ensured that the patient was given as much physical therapy as possible and given
stress techniques and exercises he could take home.

List two educational interventions you completed with your patient:

1. I educated the patient on the importance of eating a heart healthy diet. I

emphasized the importance of eating vegetables and fruits, whole grains, low-
fat dairy products, and etc.

2. I also educated the patient on his new Portacatheter and the importance of
having it with his new chemotherapy regimen.

List required referrals to two allied health services:

1. During this time we gave lots of interventions on different types of programs

 that could help with costs of the medical care given. With this being said we
referred him to a social worker and case manager.

2. We also referred him to the VA to help continue with rehabilitation services

and education opportunities on how he could live a healthier life with his new
cancer diagnosis.

SECTION SIX: APA 7th ed. References

(5 Points)

Capriotti, T. M. (2020). Pathophysiology Introductory Concepts and Clinical Perspectives

with Davis Advantage including Davis Edge (2nd ed.). F. A. Davis Company.
https://bookshelf.vitalsource.com/books/9781719642491

Gruwez, H., Proesmans, T., Evens, S., Verbrugge, F. H., Deferm, S., Dauw, J., Willems, R.,
Vandervoort, P., Haemers, P., & Pison, L. (2021). Atrial Fibrillation Population Screening.
Cardiac electrophysiology clinics, 13(3), 531–542.
https://doi.org/10.1016/j.ccep.2021.04.009

Jaakkola, S., Kiviniemi, T. O., & Airaksinen, K. (2018). Cardioversion for atrial fibrillation -
how to prevent thromboembolic complications?. Annals of medicine, 50(7), 549–555.
https://doi.org/10.1080/07853890.2018.1523552
Krishan, A., & Mittal, D. (2021). Ensembled liver cancer detection and classification
using CT images. Proceedings of the Institution of Mechanical Engineers. Part H,
Journal of engineering in medicine, 235(2), 232–244.
https://doi.org/10.1177/0954411920971888

Migdady, I., Russman, A., & Buletko, A. B. (2021). Atrial Fibrillation and Ischemic Stroke:
A Clinical Review. Seminars in neurology, 41(4), 348–364.
https://doi.org/10.1055/s-0041-1726332

Sebaaly, J., & Kelley, D. (2020). Direct Oral Anticoagulants in Obesity: An Updated
Literature Review. The Annals of pharmacotherapy, 54(11), 1144–1158.
https://doi.org/10.1177/1060028020923584