Mrs. W. has problems with oxygenation (ACS and anemia) but has prominent higher order needs as well!
Let's check out the Assessment:
Observations: The admitting nurse on CCU begins assessing the patient from the moment she lays eyes on Mrs. W. and observes that she is in no obvious physical distress with the exception of the laceration on her head. It is clear, however, that Mrs. W. is under some emotional strain. The nurse writes down the behavioral cues that give her that impression.
Vital signs: Admission vital signs indicate that Mrs. W. is somewhat more stable than she was in the ER especially in view of her pulse that is trending downward as the blood is infused.
Examination: The physical examination is fairly quick and reveals nothing untoward. On physical exam there are no outward indicators or cardiopulmonary or GI problems. Of note however, is that the menstrual pad Mrs. W was given 3 hours ago is heavily saturated with what looks like old and new blood.
Labs: As would be expected, Mrs. W's most recent heme studies show that her hematocrit and hemoglobin are improving. She has no laboratory evidence of infection and her platelet count is within low normal range. The most significant lab value is the biomarker for myocardial ischemia. A troponin level of more than 0.04 suggests heart muscle is being inadequately oxygenated. At the age of 58, Mrs. W may have some otherwise insignificant restriction to blood flow in her coronary arteries. But as her hematocrit and hemoglobin fell to critically low levels, this small "blockage" became enough to drop oxygen supply below oxygen demand for that section of myocardium. Serial troponins continue to rise as the night wears on, but the rate of increase appears to be less and this may be due to the increased oxygen carrying capacity of her blood post infusion.
Interview: In view of Mrs. W's current behavior suggesting emotional distress, it is clear that she has some unmet "higher order" needs. In this instance, these "higher order needs" are almost more urgent than the physiological ones since they were the proximal cause of Mrs. W's severe anemia. The nurse cannot be sure whether the patient is more depressed than afraid, or anxious more than guilty and self-blaming. She simply doesn't have sufficient data to make those judgments. Besides that, the nurse-patient relationship is in its earliest stages and the patient may not yet have sufficient trust to be open about her feelings. Nevertheless, the nurse needs to address these problems if only with an informed guess and a "place-holder" diagnosis. (See below).
Vital signs: Admission vital signs indicate that Mrs. W. is somewhat more stable than she was in the ER especially in view of her pulse that is trending downward as the blood is infused.
Examination: The physical examination is fairly quick and reveals nothing untoward. On physical exam there are no outward indicators or cardiopulmonary or GI problems. Of note however, is that the menstrual pad Mrs. W was given 3 hours ago is heavily saturated with what looks like old and new blood.
Labs: As would be expected, Mrs. W's most recent heme studies show that her hematocrit and hemoglobin are improving. She has no laboratory evidence of infection and her platelet count is within low normal range. The most significant lab value is the biomarker for myocardial ischemia. A troponin level of more than 0.04 suggests heart muscle is being inadequately oxygenated. At the age of 58, Mrs. W may have some otherwise insignificant restriction to blood flow in her coronary arteries. But as her hematocrit and hemoglobin fell to critically low levels, this small "blockage" became enough to drop oxygen supply below oxygen demand for that section of myocardium. Serial troponins continue to rise as the night wears on, but the rate of increase appears to be less and this may be due to the increased oxygen carrying capacity of her blood post infusion.
Interview: In view of Mrs. W's current behavior suggesting emotional distress, it is clear that she has some unmet "higher order" needs. In this instance, these "higher order needs" are almost more urgent than the physiological ones since they were the proximal cause of Mrs. W's severe anemia. The nurse cannot be sure whether the patient is more depressed than afraid, or anxious more than guilty and self-blaming. She simply doesn't have sufficient data to make those judgments. Besides that, the nurse-patient relationship is in its earliest stages and the patient may not yet have sufficient trust to be open about her feelings. Nevertheless, the nurse needs to address these problems if only with an informed guess and a "place-holder" diagnosis. (See below).
Problem Statements
Problem Statement #1: Impaired tissue oxygenation (brain and heart) RT decreased oxygen carrying capacity of the blood AEB loss of consciousness and myocardial ischemia.
This is a straightforward (even simple-minded) physiological description of what happened to Mrs. W. The two most oxygen demanding organs in the body are the brain and the heart. It stands to reason that as her hemoglobin levels began to fall to critical levels, symptoms would arise involving the heart and head. From this very logical description of the patient's problem the nurse can (1) begin planning care immediately and (2) more easily find a final, authorized NANDA-I diagnosis at a later date.
Problem Statement #2: Impaired situational safety RT dx of acute coronary syndrome (ACS) and helplessness/fear of procedural pain.
Certain things seem clear: (1) the loss of consciousness, ACS and head injury happened after the patient had been denying and ignoring her condition for quite a long time. Confronted with this sudden deterioration in her physical health, one she can no longer deny, Mrs. W. can no longer feel situationally safe and emotionally secure. (2) When Mrs. W. explained to the physician the reasons for her failure to seek care for her dysfunctional uterine bleeding, her comments focused upon her utter loss of self-control and the indignity with which she was treated many years ago.
This is a straightforward (even simple-minded) physiological description of what happened to Mrs. W. The two most oxygen demanding organs in the body are the brain and the heart. It stands to reason that as her hemoglobin levels began to fall to critical levels, symptoms would arise involving the heart and head. From this very logical description of the patient's problem the nurse can (1) begin planning care immediately and (2) more easily find a final, authorized NANDA-I diagnosis at a later date.
Problem Statement #2: Impaired situational safety RT dx of acute coronary syndrome (ACS) and helplessness/fear of procedural pain.
Certain things seem clear: (1) the loss of consciousness, ACS and head injury happened after the patient had been denying and ignoring her condition for quite a long time. Confronted with this sudden deterioration in her physical health, one she can no longer deny, Mrs. W. can no longer feel situationally safe and emotionally secure. (2) When Mrs. W. explained to the physician the reasons for her failure to seek care for her dysfunctional uterine bleeding, her comments focused upon her utter loss of self-control and the indignity with which she was treated many years ago.
Goals:
Goals for Problem #1: The first diagnosis is simple and straightforward and so are the associated goals. The symptoms of tissue ischemia were caused by Mrs. W's anemia. If the transfused blood corrects the anemia, then the symptoms should gradually reverse. Two sets of symptoms are selected by the nurse as useful markers for the success of the collaborative treatments (blood infusion.) They are stated in terms of the patient, are in a time context and are either binary or quantifiable.
Goals for Problem #2: The patient's problems with helplessness and insecurity are not reversed by making her more dependent upon the staff. Therefore, the nurse attempts to put the patient in control of as much of her care as possible. In order to do this, the nurse facilitates the patient's involvement in her care as much as possible. Insecurity cannot be fixed in a fact-vacuum. Consequently, the nurse facilitates as much as possible the patient's access to information relevant to getting the biopsy she has long put off.
Goals for Problem #2: The patient's problems with helplessness and insecurity are not reversed by making her more dependent upon the staff. Therefore, the nurse attempts to put the patient in control of as much of her care as possible. In order to do this, the nurse facilitates the patient's involvement in her care as much as possible. Insecurity cannot be fixed in a fact-vacuum. Consequently, the nurse facilitates as much as possible the patient's access to information relevant to getting the biopsy she has long put off.
Actions:
Actions for Problem #1: The actions for this simple problem statement are largely self-evident and collaborative. Mrs. W. needs blood and that is the principle action for the nurse. As part of that process, and because Mrs. W. has had what appears to be a STEMI, the nurse outlines the close monitoring planned for the remainder of the night. Mrs. W. is at high risk of fall and the nurse consequently prescribes how and under what conditions Mrs. W. will be allowed out of bed. Just as the infusion of blood is relevant to this problem, so is blood loss. Therefore the nurse provides for a system for semi-quantification of vaginal bleeding. Obviously, Mrs. W's anemia was severe enough to rob her of almost all energy. Recognizing this, the nurse institutes a plan for allowing Mrs. W. as much time to recharge between nursing tasks as possible.
Note: Why is the nursing action pertaining to Mrs. W's husband listed under this first problem statement? For the answer... see below.
Note: Why is the nursing action pertaining to Mrs. W's husband listed under this first problem statement? For the answer... see below.
Fear, tension, and pain are acute stressors on the body that activate the hypothalamic-pituitary-adrenal axis. This results in an increased secretion of cortisol and increased activation of the sympathetic nervous system. Increased epinephrine and norepinephrine in Mrs. W’s system increases cortical vigilance (makes her more awake, even if she’s exhausted), and drives her heart and blood pressure in excess of any immediate need… further exhausting her physical reserves. The excessive release of cortisol (stress hormone) has a potent anti-inflammatory effect and damages her ability to fight infection and begin tissue healing.
Mrs. W. was clearly anxious, even if not experiencing tremendous pain. It was clear that her husband’s presence was comforting to her. Therefore, dealing with these “higher order” problems was intended by the nurse to relieve some of the burden on Mrs. W’s heart.
Mrs. W. was clearly anxious, even if not experiencing tremendous pain. It was clear that her husband’s presence was comforting to her. Therefore, dealing with these “higher order” problems was intended by the nurse to relieve some of the burden on Mrs. W’s heart.
Actions for Problem #2: The actions associated with this higher order need aims at providing Mrs. W. with every resource possible to inform herself about her condition, her insurance, and her medical options. The nurse validates Mrs. W's right to feel resentment for the way she was treated previously and suggests a means of choosing a physician she can trust. Mrs. W and her husband together review physicians available to her and the ratings other patients have given them. Also, the nurse supports the W's rights to fully understand the care they may need and take responsibility for getting it through formation of a questions list.
Evaluations:
For Problem #1: Again, the first problem statement is simple and largely collaborative. It is nevertheless important for the nurse to note that the blood replacement is having the desired physiological effects.
For Problem #2: There is tangible evidence (smiling, visiting with friends) that Mrs. W was less distraught in the morning than she was at the time of admission the night before. With the help of her husband, Mrs. W. is able to address her responsibility to chose a care-giver (gynecologist) likely to understand her needs, and they are similarly making a conscious list of what those needs are, instead of relying on unconscious or nebulous fears.
For Problem #2: There is tangible evidence (smiling, visiting with friends) that Mrs. W was less distraught in the morning than she was at the time of admission the night before. With the help of her husband, Mrs. W. is able to address her responsibility to chose a care-giver (gynecologist) likely to understand her needs, and they are similarly making a conscious list of what those needs are, instead of relying on unconscious or nebulous fears.
Hey... wait a minute!!! In the emergency room and in the CCU, wherever Mrs. W's vital signs were taken, her %sat was consistently 99-100. If that's the case, then how could she be experiencing tissue hypoxia?
Simple: The % sat is only a measure of the % of binding sites occupied by oxygen on Mrs. W's hemoglobin. It tells us nothing about the amount of hemoglobin present. Mrs. W. was ischemic not because her RBC's couldn't pick up oxygen, but because she didn't have enough of them!
Simple: The % sat is only a measure of the % of binding sites occupied by oxygen on Mrs. W's hemoglobin. It tells us nothing about the amount of hemoglobin present. Mrs. W. was ischemic not because her RBC's couldn't pick up oxygen, but because she didn't have enough of them!