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Holistic Assessment and Care Plans

Introduction

Cardiogenic shock is a condition caused by decreased cardiac output due to impaired contractility of the heart. Acute myocardial infarction is the main cause of cardiogenic shock which leads to multiple organ failure (Van Diepen et al., 2017). The patient developed this condition after post coronary angioplasty due to myocardial infarction. Occlusion of the coronary artery which causes the death of myocardial tissue leads to myocardial infarction.

Objectives

The objectives are to increase the patient’s cardiac output and tissue perfusion by decreasing ventricular afterload, lowering oxygen demand, and boosting oxygen delivery to the heart.

Interventions

The patient’s therapies include establishing continuous ECG and hemodynamic monitoring, closely monitoring adverse medication therapy reactions, continually monitoring blood pressure using an intra-arterial line, and recording intake and urine output.

Holistic Assessment

One of the most critical abilities a nurse has in this circumstance is estimating pain. The chest pain was evaluated using the ‘PQRST’ pain evaluation tool. The tool assessed pain’s causative or palliative causes, quality, location or radiation, severity, and time parameters (Toney- Butler & Unison, 2018). Exertion, cold, emotional stress and smoking are elements that trigger ischemia discomfort (Anderson & Morrow, 2017). Medications such as nitroglycerin, which alleviates pain in myocardial infarction, are considered palliative factors. Chest discomfort caused by myocardial infarction has a tightness, pressure, or constricting character. The pain frequently begins in the center or left side of the chest and travels to the shoulder, arm, neck, or jaw. The ten-point scale assigns a severity rating to pain, ranging from 0 (no pain) to 10 as most excruciating. Dyspnoea, nausea, feeling dizzy, a chilly sweat, or fatigue are associated symptoms. Myocardial infarction causes pain that lasts longer than a few minutes.

Care Plan for Formal Diagnosis

date Nursing diagnosis Goals and outcomes interventions evaluation
Decreased cardiac output related to impaired contractility due to extensive heart muscle damage. After 15 minutes of nursing interventions the patient’s vital signs will be within acceptable limit. Independent
  • Obtain HR, RR, and BP every 15 minutes to detect cardiopulmonary deterioration.
  • Auscultate apical pulse.
  • Palpate peripheral pulses.
  • Monitor BP
  • Monitor urine output
  • Encourage rest

Dependent

  • Administer medications as prescribed.

Collaborative:

  • Administer oxygen, monitor vitals, and check lab works (Tehrani et al., 2020).
After 15 minutes of nursing interventions the patient’s vital signs will be within acceptable limit.

Care Plan for Current Symptoms

date assessment diagnosis outcomes Interventions rationale evaluation
Patient is in CCU and is responding to verbal command. Subjective
  • Patient is in CCU

Objective

  • RR 12 breaths /min.
  • Oxygen saturation is 93%.
  • HR 115 beats/min.
  • BP is 80/50mmHg.
  • Tachycardia.
  • Pedal pulses are present.
  • Oliguria.
Decreased cardiac output related to impaired contractility due to extensive heart muscle damage. After 15 minutes of nursing interventions the patient’s vital signs will be within acceptable limit. Independent
  • Obtain HR, RR, and BP every 15 minutes to detect cardiopulmonary deterioration.
  • Auscultate apical pulse.
  • Palpate peripheral pulses.
  • Monitor BP
  • Monitor urine output
  • Encourage rest

Dependent

  • Administer medications as prescribed.

Collaborative:

  • Administer oxygen, monitor vitals, and check lab works (Tehrani et al., 2020).
To establish base line.
Tachycardia is usually present.
Physical rest should be maintained to decrease oxygen demand by body.
Diminished peripheral pulses indicates decreased cardiac output (Roth et al., 2018).
When there is decreased cardiac output the kidneys retain water and sodium.
After 15 minutes of nursing interventions the patient’s vital signs will be within acceptable limit.

Reference List

Anderson, J.L. and Morrow, D.A. (2017). Acute myocardial infarction. New England Journal of Medicine, 376(21), pp. 2053-2064.

Toney-Butler, T.J., and Unison-Pace, W.J. (2018). Nursing admission assessment and examination.

Van Diepen, S., Katz, J.N., Albert, N.M., Henry, T.D., Jacobs, A.K., Kapur, N.K., Kilic, A., Menon, V., Ohman, E.M., Sweitzer, N.K. and Thiele, H., 2017. Contemporary management of cardiogenic shock: a scientific statement from the American Heart Association. Circulation, 136(16), pp.e232-e268.

Tehrani, B.N., Truesdell, A.G., Psotka, M.A., Rosner, C., Singh, R., Sinha, S.S., Damluji, A.A. and Batchelor, W.B., 2020. A standardized and comprehensive approach to the management of cardiogenic shock. JACC: Heart Failure, 8(11), pp. 879-891.

Roth, S., Fox, H., Fuchs, U., Schulz, U., Costard-Jäckle, A., Gummert, J.F., Horstkotte, D., Oldenburg, O. and Bitter, T., 2018. Noninvasive pulse contour analysis for determination of cardiac output in patients with chronic heart failure. Clinical Research in Cardiology, 107(5), pp. 395-404.

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StudyKraken. (2022, November 23). Holistic Assessment and Care Plans. Retrieved from https://studykraken.com/holistic-assessment-and-care-plans/

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StudyKraken. (2022, November 23). Holistic Assessment and Care Plans. https://studykraken.com/holistic-assessment-and-care-plans/

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StudyKraken. "Holistic Assessment and Care Plans." November 23, 2022. https://studykraken.com/holistic-assessment-and-care-plans/.

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StudyKraken. 2022. "Holistic Assessment and Care Plans." November 23, 2022. https://studykraken.com/holistic-assessment-and-care-plans/.

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StudyKraken. (2022) 'Holistic Assessment and Care Plans'. 23 November.

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