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Primary Diagnosis: AFIB, with RVR--- admitted for rate control and started on a Cardizem drip and then transferred over
to amlodipine (rate control) elevated D dimer and BNP.
Integrated Pathophysiology:
Patient was admitted for rate control and was started on a Cardizem drip. She had an elevated D dimer, and BNP. The D-
dimer indicates an elevation in coagulation in the body. BNP is a hormone secreted in your brain in response to elevated
blood pressure. This is a compensatory mechanism to help the body to decrease BP to normal ranges.
Atrial fibrillation is a heart condition where the electrical conducting system of the heart is not functioning adequately.
Instead of the atrium contracting normally, it is quivering. This leads to pooling of blood, and potential for clot
formation. Clot formation can lead to pulmonary embolisms. Patients D-dimer results reflect that the body has already
formed clots. Because of this, patient has been started on Coumadin, and Lovenox. Patient was placed on continuous
ECG monitoring to monitor her hearts electrical conduction.
Rapid ventricular rate is another abnormality in electrical conduction of the heart that occurs secondary to atrial
fibrillation. The heart rate with Afib and RVR can be up to or greater than 200 beats per minute.
These abnormalities are dangerous because there is a greater chance of clot formation, and PE. Also, because the heart
is not completing a full diastolic/systolic function, the heart is not filling up with an adequate amount of oxygenated
blood, and is therefore, not delivering oxygen rich blood to nourish the tissues of the body.
The goal with this patient is to slow her heart rate, and decrease her blood pressure. The idea is that her heart can fill
with blood fully to be able to nourish the body to meet its needs.
Data Collection
Diet (Type): Cardiac diet IV: NS 60 ML/hr
I&O: BID CBG: None
Fall Risk/Safety Precautions: Fall Risk Activity: Ambulate in room only TID with assistance
Wound Care: None Oxygen: none
Drains: None Last BM: AM 11/7, large, formed, light grey/brown.
Other Tubes: None
ASSESSMENTS
Integumentary: Head and Neck:
Skin is in good condition. Pink, warm, hydrated. Patients trachea is midline.
Some bruises are located on lower and upper bilateral Hair thick, scalp clean.
arms secondary to venipuncture. LN non-palpable
Face symmetrical, and expression calm.
Ear/Nose/Throat: Thorax/Lungs:
Patient has all her natural teeth. Wheezes throughout lung field. Right upper worse than
She can swallow on her own, and is not at risk for any other field. Crackles is posterior bilateral bases.
aspiration. Patient is coughing up copious amounts of yellow sputum.
Patient does not have a hearing problem. She states that her chest hurts.
Cardiac: Musculoskeletal:
Dysrhythmia auscultated.
Peripheral pulses bounding +3, but equal. Patient states that she has an old rib injury.
Tachycardia present. She is able to ambulate without difficulty, and is not a fall
Trace edema to lower extremities risk.
JVD present/ measured at 5 cm.
CRT < 3 seconds.
Genitourinary: Gastrointestinal:
Output is excessive due to diuretics. Normoperistaltic sounds in all four quadrants.
No abdominal pain with auscultation.
A&O X4 T 98.9 F
All cranial nerves intact. P 133
Strength to upper and lower extremities present, WNL. R 16
No paresthesia noted. BP 154/80
SPO2 sat 96% RA
Pain 2/10
CURRENT MEDICATIONS
Generic & Classification Dose/Route/ Onset/Peak Intended Adverse reactions Nursing Implications for this
Trade Name Rate if IV Action/Therapeuti client.
c use.
EXT/REL Onset 30
Gauifenesin/ Therapeutic: allergy, 1200 MG PO mins Reduces viscosity dizziness Look for orthostatic
Mucinex cold, and cough BID Peak of tenacious hypotension before having
remedies, expectorant Unknown secretions by patient ambulate
increasing
respiratory tract
fluid.
DIAGNOSTIC TESTING
11/07/2017 @ 1000
Data: Patient had a non-patent IV to right hand, but patient requires an IV because she is on a medication to slow her
heart rate.
This requires emergency venous access.
Action: Patient educated on reasons for needing another IV. Nursing student prepared, and placed 20 G IV into left
wrist.
Response: IV was patent and flushed well. Patient denied pain.
11/07/2017 @1100
Data: Patient was given an incentive spirometer to improve lung function.
Action: Student nurse discussed how incentive spirometer works, what the goal of the treatment is, and how to use the
apparatus.
Response: Patient maintained ball of spirometer in the best range for 5 seconds. She will continue to use I.S. 10 times
per hour.
11/07/2017 @1300
Data: With exam, it is noticed that patient has a distended artery in her neck. Student nurse thinks that it is a carotid
artery pulsating.
Action: Student nurse asks charge nurse about finding. Doctor overhears conversation and states that there is no way it
would be a carotid artery due to muscle coverage- it would have to be JVD.
Response: Student realizes that she has never seen JVD in the clinical setting. Explains to patient the finding and
measure the JVD. It measured at 5 CM.
Patient Information:
Afib with RVR, CHF, HTN, pulmonary edema, bronchitis, pneumonia.
Nursing Diagnosis should include Nanda Nursing Diagnostic statement, related to (R/T), as evidenced by (AEB).
Problem #1 Decreased cardiac output R/T decreased contraction of atrium AEB pooling of blood in the right
atrium, clot formation, and signs of edema.
Evaluation:
Patients edema was only trace today, but was 2+yesterday.
Problem #2 Impaired gas exchange R/T fluid in the pulmonary interstitial space AEB radiographs that
diagnose pulmonary edema, and dyspnea with exercise.
Patients SPO2 stayed in the 90 percentile today. She only complained of being SOB twice. She recovered quickly post
dyspneic episode.