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BSMCON NUR 3111P 1

Contributing factors: HTN, BPH,


hypokalemia, age, race
Congestive Heart Failure (CHF): specifically
Hypertension (HTN) systolic heart failure

Cardiomyopathy is a primary
Sustained high BP increases cause of CHF. Because of the
cardiac workload and produces A.C., 73 yo, A.A., male
Non-ischemic cardiomyopathy ventricular dilation and
left ventricular hypertrophy. impaired systolic function in
Progressive hypertrophy is dilated cardiomyopathy, the
associated with the development workload of the heart is
of heart failure, which can be increased which results in
caused by cardiomyopathy. decreased cardiac output.
(Lewis; pg. 714) CHF is caused by interference RBC: 3.59 M/uL low due to anemia
with the normal mechanisms Hgb: 10.5 g/dL low due to anemia
Hct: 33.1% low due to anemia
Nursing diagnosis: Decreased cardiac output related to alteration in Non-ischemic cardiomyopathies include four regulating cardiac output. Platelet: 131 K/uL low due to anemia
heart rate, rhythm, and conduction as evidenced by abnormal heart (Lewis; pg. 767)
types of heart muscle diseases that are not Hospital problems list hypokalemia, but I did not see a test
sound (S3). related to CAD. The patient presented here has for this.
dilated cardiomyopathy. Dilated EKG, 12 lead, initial (10/29/2015) showed sinus rhythm
Goal: During shift, from 0700 to 1500, patient will maintain cardiomyopathy is characterized by a diffuse with 1st degree AV block with occasional premature
adequate cardiac output as evidences by systolic BP within 20mmHg inflammation and rapid degeneration of ventricular complexes and premature atrial complexes; left
of baseline; heart rate 60-100 beats per minute with regular rhythm; myocardial fibers. This results in ventricular axis deviated; and LV hypertrophy with QRS widening with
and orientation to person, place, and time. dilation, impaired systolic function, atrial strain pattern.
enlargement, and stasis of blood in the left NM Cardiac Spectrum with Stress/Rest Mult.
Interventions: ventricle (Lewis; pg. 827) (11/02/2015): inferolateral infarct suggested LV EF 29%
1.) Assess heart sounds for gallops (S3, S4); S3 denotes reduced LV
Medications for these conditions overlap: 2D Echo Complete: showed LV moderately dilated; systolic
ejection and is a classic sign of LV failure. S4 occurs with reduced
Amlodipine 10mg, 1T, PO, QD: antihypertensive decreases BP by dilating function moderately reduced; EF 35%; moderate diffuse
compliance of LV, which impairs diastolic filling.
coronary arteries and arterioles hypokinesis; wall thickness moderately increased. LA
2.) Administer medication as prescribed, noting response and
Aspirin 81mg, 1T, PO, QD: antiplatelet interferes with clotting by keeping a moderate to severely dilated. Mitral valve moderate
watching for side effects and toxicity. Clarify with the physician Psychosocial/spiritual
platelet-aggregating substance from forming regurgitation. A trivial periocardial effusion
parameters for withholding medications; depending on etiological needs and discharge needs:
factors, common medications include digitalis therapy, diuretics, Hydralizine 25mg, 1T, PO, TID: antihypertensive direct-acting vasodilator Patient had an AICD
vasodilator therapy, antidysrhythmics, angiotensin-converting that relaxes arteriolar smooth muscle implant procedure and will
enzyme inhibitors, and inotropic agents. Fosinopril 40mg, 1T, PO, QD: antihypertensive Reduces sodium and water need to be kept calm. He
3.) Explain the drug regimen, purpose, dose, and side effects; retention and lowers BP by inhibiting RAAS will need reassurance that
information provides rationale for therapy and aids the patient in Isosorbide Mononitrate ER 30mg, 1T, PO, QD: antianginal decrease cardiac he will recover. He enjoys
Anticipated
assuming responsibility patient
for self-care teaching:
later. O2 demand by decreasing preload and afterload having company and
Teach about new medications Metoprolol 100mg, 1T, PO, BID: antihypertensive decreases cardiac output, responds to a caring touch.
Evaluation: Teach about AICD. peripheral resistance, and cardiac O2 consumption; and depresses renin He was not discharged, but
Teach about
Goals met. Patient maintained BPincision care.
and heart rate within stated limits secretion. was moved to another unit.
Teach about follow up
and was oriented times 4 during the entire shift.appointments making sure to Enoxaprin 40mg, injection, subcutaneous, Q24H: anticoagulant prevents Once he has recovered
note that he will have to be seen every 3 months for the conversion of fibrinogen to fibrin. from surgery, he will be
rest of his life. Terazosin 2mg, 1C, PO, QHS: antihypertensive reduces peripheral vascular placed in a rehab facility.
Teach about proper diet and exercise and knowing resistance and BP via arterial and venous dilation.
when to rest/ importance of rest. Vancomycin 1,500mg in NS 500mL infusion: dose 1,500mg IV: antibiotic
Make sure patient knows when to call for help and what hinders bacterial cell-wall synthesis. (Prophylaxis for surgical procedure)
signs to look for in exacerbation of CHF. Physical Assessment

Assessment Findings
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Safety Falling star, fall risk level 2, noted pressure ulcer risk in record, Schmid score: 2, urinal at bedside, bed in
lowest position with HOB elevated, bedrails times 2, call bell within reach, identification bracelet in place
as well as fall risk bracelet, non-skid socks, full code
Skin/Wounds Skin warm, dry, intact, color appropriate for race, turgor elastic, Braden score 17. No evidence of
wounds, Patient turns self, able to ambulate with one assist, lotion applied to feet, face washed
Respiratory Lung sounds clear, no cough present, on room air, RR 16, SpO2 98%, breathing unlabored at rest and
during ambulation
Cardiovascular Patient on tele-monitor, HR regularly irregular: S1, S2, with additional sound (S3), radial pulses +3
bilaterally, pedal pulses +3 bilaterally, capillary refill brisk, no JVD noted, no edema, BP 174/99 at 0721,
down to 151/79 at 1100, HR 80 at 0721 down to 65 at 1100
Gastrointestinal Bowel sounds normoactive in all 4 quadrants, abdomen soft, non-tender, last BM 11/03/2015 (patient
stated; normal), patient denied n/v/d, diet NPO
Genitourinary Patient is continent with urinal within reach. Voided 3 times (0721, 0836, 1100) totaling 400mL, urine
clear yellow/straw, no odor
Neurological A and O times 4, clear speech, PERRLA noted (sluggish pupils), cranial nerves intact, speech was
purposeful and conversation flowed, no confusion and no complaints of dizziness during shift, aware of
pending procedure and good understanding
Musculoskeletal Grips equal 5/5 bilaterally upper and lower extremities, push pull 5/5 equal bilaterally upper and lower
extremities, dorsi/plantar flexion 5/5 bilaterally. PT came to walk: gait steady with walker, leans a bit to
the right and drags right foot at times, up with one assist. Sat in chair for a while. Movements purposeful
IV Lines 20 gauge PIV left arm saline locked until surgery; transparent dressing, clean dry and intact, no signs of
Drains/Equipment infiltration or infection. Other equipment used: urinal, walker, tele-monitor

List two goals for the next practicum experience:


1. I am looking forward to seeing what time management is like with 2 patients.
2. I have a habit of questioning a lot of things in the chart. My personal goal is to relax a little when it comes to what others chart.

Guide for Reflection


Guide for Reflection Using Tanners (2006) Clinical Judgment Model
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Refer to the Toolkit for the questions to guide your reflection

Highlight the program thread that is most applicable to this reflection:


Communication and collaboration
Caring and the Catholic Health Ministry
Servant Leadership and Global Health
Safe, Quality, Evidence-based practice
Professionalism and commitment to Lifelong Learning

Introduction
I had a patient today who was diagnosed with cardiomyopathy with systolic heart failure and was scheduled to have an AICD implant in the cardiac cath lab. He
was NPO and had been since yesterday after dinner. He is a very kind man who lives alone, is not married, has no children, and some brothers and a sister who
do not live close by. He does have a close friend whom he relies on for emergencies and he was a generally happy person. I had the pleasure of taking care of
him this morning and it was really a pleasure to care for someone like him.

Background
I established trust with my patient immediately. His pleasant disposition and eagerness to do as he was instructed really touched my heart and we got along very
well. While I took his vital signs and did my head to toe assessment, we talked about his life and what had brought him to the hospital. I asked him if he knew
about the procedure he was scheduled for and he confirmed that he did. He told me that the doctor said that he needed an internal device to defibrillate him if he
had a wrong rhythm. He said he was not nervous and was just ready to get it over with so he could eat because he was very hungry. My heart went out to him
as my stomach growled around 0830 that morning. This man had not eaten since the previous day, was hungry, and was not even complaining. As I periodically
checked in on him, he asked me if I had found out what time he would go down for his procedure. It was unfortunate, but we had no idea of the time. We waited
and waited and waited until about 1130 when we got the call saying that they were coming for him. He amazed me because he was not only relieved, but also
seemed excited. I believe that he was just so happy to be getting it over with. I told him that I would be going with him and he was very happy about that. I was
too.
Noticing
As I stated above, I noticed that my patient seemed almost excited to have this procedure done. As I spent more time with him and time thinking about his
situation, I began to realize that it wasnt the procedure he was excited about at all. He was excited that getting it over with meant that he would be able to eat
something. Even though he didnt complain, he was very hungry. He was also happy that he was going to be fixed. He understood how important the
procedure was for his health and was looking forward to getting back on his feet and out of the hospital. These may seem like small things, but these things
made him very happy. I dont know if I have ever had a patient who was just so grateful for the help they were receiving.

Interpreting
I dont know if I have ever had a patient who was just so grateful for the help they were receiving. Since he was unable to eat, I had an idea to help him feel
better. I asked him if he would like to brush his teeth. Oh my goodness, you would have though I hung the moon. I got him all set up and he brushed for a good
2-2.5 minutes and when he was finished, he said he felt so much better and that it was such a good idea and just thanked me over and over again. Just brushing
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his teeth was a joy to him. It just amazed me at how these things could make him so happy. Especially since he was going to have a procedure done on his heart.
Something I consider a very risky procedure and anytime you have to use anesthesia, it is a risk. Most patients would have been scared or solemn. They would
have become impatient and maybe angry because they were so hungry. This man was nothing but pleasant. PT came to his room to work with him and he gladly
got up and walked up and down the hall. Students came in to listen to his heart because he had an extra beat and he loved it. When it was finally time to go, he
began to look a little worried. I touched his shoulder and assured him that everything was going to be okay and that I would be with him the whole time. It felt
really good to now that I was able to put him at ease and not only that, but I was also able to make him happy.
Responding
After being with my patient that morning, I made a goal that I would not let him be alone. He really enjoyed company and he didnt have anyone who could be
with him. I checked in on him more than once an hour and when I went into his room to take his vitals, I lingered for a little while. I found myself making
excuses just to check in on him. I wanted to make sure that he stayed happy and optimistic. I also wanted to bring more people in to see him, so I grabbed a
couple of my classmates (one at a time) and brought then in to meet him and listen to his heart. He loved the attention.

Reflection-in-Action:
The reason I chose professionalism and lifelong learning is because this man made me see that I still have a lot to learn. Not every patient is going to react to a
situation the same as the one before. Some people may live alone and seem to have lonely lives, but they can still be happy people. Sometimes we go into a
situation with preconceived notions as to what it will be like. We judge the patient and their situation before we even lay eyes on them and that is not fair. I also
chose this topic because I got to go to the cath lab to see the surgery. It was an amazing experience and I found that I truly enjoyed it and I learned a lot from the
people in the lab and the doctor performing the surgery. One of the nurses there asked me if I knew what kind of nursing I wanted to do. I responded that I
thought I did, but as I experience new things, I am not so sure anymore and I would just have to wait and see.
Reflection-on-Action and Clinical Learning
Three ways my nursing skills expanded during this experience, I learned to be patient with doctors and labs because they are busy and you may be waiting all
day before your patient gets to go to their procedure. I practiced observation as I listened to my patient and observed his behavior and not just his physical signs
and symptoms. I paid attention to his feelings and gained an understanding of how he was feeling and why. I listened to his unusual heart sound and learned that
I am more capable of noticing things than I thought I was. I was the first to note the S 3 in his chart, but the nurse I was with confirmed that I was really hearing it
and not imagining it.

One thing I might do differently if I encounter this situation again is to call down to the cath lab to see if they can give me any indication of when my patients
turn will come. I would have like to sit and read with him too or if I didnt have time, suggest that a sitter come to read with him. It would have been nice to find
a book or a puzzle to keep him busy while he was waiting. He seemed bored at times. I would say that these things also go along with additional knowledge and
skills I would need if I encounter a situation like this again. I need to know where to find books or puzzles and who to call to find someone to sit with him and
keep him company. I would ask him more about what he likes to do with free time like that.
Until today, I thought every patient I was going to have on that unit would be similar. Not to be misunderstood, I have had patients that are happy or grateful for
things, but I just havent been enjoying my encounters as much. I realize now that some days are going to be better than others and while nursing is a very
fulfilling career, not every day of it is fulfilling. I have been grateful for any experience I can get as a student nurse and I have really enjoyed this unit overall. I
know that it is not the place I want to be when I graduate, but that is okay. I also learned today that no matter where I go or what field I choose, I am going to
have days where I just dont want to be there or I am not feeling fulfilled (it is like that with any career). Then there are days like today when you meet a very
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special patient who reminds you that there are a lot of days when you will leave happy. And there will be a lot of days to be proud of and that is what makes it all
worthwhile.
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Lasater Clinical Judgment Rubric Scoring Sheet


Developed by Kathie Lasater, Ed.D.; Based on Tanners Integrative Model of Clinical Judgment (2006)

Student Name: Date/Time: Clinical Site:

Clinical Judgment Components Notes


Noticing:
Focused Observation: B D A E
Recognizing Deviations from Expected Patterns:
B D A E
Information Seeking: B D A E
Interpreting:
Prioritizing Data: B D A E

Making Sense of Data: B D A E


Responding:
Calm, Confident Manner: B D A E
Clear Communication: B D A E
Well-Planned Intervention/Flexibility: B D A E

Being Skillful: B D A E

Reflecting:
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Evaluation/Self-Analysis: B D A E
Commitment to Improvement: B D A E
Summary Comments: