CASE BASE PRESENTATION ON VENTRICULAR TACHYCARDIA (VT)

• DISCUSS CASE SCENARIO OF THE PATIENT CONTAINING PAST HISTORY AND PRESENT COMPLICATIONS

• DEFINE VENTRICULAR TACHYCARDIA AND IT’S PATHOPHYSIOLOGY

• EXPLAIN CAUSES, SIGN AND SYMPTOMS RELATED TO THE DISEASE

• INTEGRATE DIAGNOSTIC TESTS AND LAB REPORTS OF THE PATIENT

• LOOK INTO MEDICAL AND NURSING MANAGEMENT OF THE PATIENT

• TALK ON ASSESSMENT DONE THROUGH FHP AND PHYSICAL EXAMINATION OF THE PATIENT

• LIST DOWN RELEVANT NURSING DIAGNOSIS

• DISCUSS NURSING INTERVENTIONS WHICH WERE APPLIED ON THE PATIENT

• TALK ABOUT TEACHING PLANS WHICH WERE GIVEN TO THE PATIENT AND HIS FAMILY

• GIVE REFERENCES

REASON FOR SELECTING THE PATIENT• The patient was with multiple diagnosis which was helpful for students in acquiring further

knowledge and information.

• During interviewing and from patient’s file we noticed that patient is suffering from multiple diseases.

• Patient and his family expressed for the need of further information about the disease process.

• Many interventions could be taken on this patient.

A 72 year old male k/c IHD, MI (1999-s/p CABG 2000) came to AKUH ER with feeling of suffocation, exertional chest pain, heaviness and SOB for the last one day. ECG was done which showed monomorphic ventricular tachycardia with heart rate of 150/minute. He was given shocked with 100J. Baseline investigation was done and diagnosed as a case of VT, metabolic acidosis, AKI, cardiogenic shock, NSTEMI and aspiration pneumonia.

When he was admitted in CCU he was intubated. A hemodialysis was done on 2/3/2016 which was tolerated well. He got extubated on 4/3/2016. Iv antibiotics were given as blood cultures showed acinobacter. Second session of hemodialysis was done on 7/3/2016 and 3rd on 8/3/2016. Patient has improved became vitally stable, maintaining respiration at RA, Patient family was so concerned due to inattentive behavior of patient against taking medicine. They wanted us to give further information about the disease process.

PAST HISTORY OF THE PATIENT IHD (Ischemic heart disease) CHF (Congestive heart failure)

CABG (Coronary Artery Bypass Grafting) 2000 Hypertension

Ventricular aneurism

VENTRICULAR TACHYCARDIA

Ventricular tachycardia arises from improper electrical activity of ventricles of the heart. This is a life threatening arrhythmia because it can cause low blood pressure and may lead to ventricular fibrillation, asystole and sudden death.

ANATOMY AND PHYSIOLOGY OF THE HEART

PATHOPHYSIOLOGY

IHD (plaque formation in coronary arteries)

Hypo perfusion to myocardium

CHF (heart muscles became week)

Impaired contractility due to CHF which causes fibrillation

Ventricular tachycardia

Cardiomyopathy (weakens the heart muscles)

Structural heart disease (result of heart damage from previous heart attack)

Ischemic heart disease (lack of blood flow to the heart)

Heart Failure (Inability to pump adequate amount of blood)

Causes

Valvuler heart disease

Scar (due to any previous heart surgery)

Electrolyte imbalance (minerals that regulate heart rhythm

Hereditary (family history of hearth rhythm disorders or more likely to develop ventricular

tachycardia

Continue..

SIGN AND SYMPTOMS OF VT

CEST PAIN SHORTNESS OF BREATH

PALPATIONS

IRREGULAR HEART BEATING

CONTINUE…

DIZZINESS ORTHOPNEA FAINTING

WEAK PULSE OR NO PULSE

PRESENT COMPLICATIONS OF THE PATIENT

NSTEMIPARTIALLY BLOCKAGE OF CORONARY

ARTERIES CAUSE REDUCE BLOOD SUPPLY TO THE HEART MUSCLE

CARDIOGENIC SHOCKSHUT DOWN OF VITAL

ORGANS DUE HYPO PERFUSION

ACUTE LIVE FAILUREDUE TO HYPO PERFUSION TO

THE LIVER

CONTINUE…

KIDNEY FAILURE DECREASED CARDIAC OUTPUT

DECREASED PERIPHERAL VASCULAR RESISTANCE

RENAL ARTERY OBSTRUCTION

SEPSISINFECTION DUE TO LOW IMMUNE

SYSTEM AND PROLONG HOSPITALIZATION

METABOLIC ACIDOSISDUE TO KIDNEY FAILURE

CONTINUE…

THROMBOCYTOPENIACONDITION OF LOW PLATELET

COUNT

ASPIRATION PNEUMONIA

INHALATION OF SECRETION INTO AIRWAY

MOUTH ULCERDUE TO CARDIAC MEDICATIONS

DIAGNOSTIC TESTS

ELECTROCARDIOGRAM

• Ecg is done in er which showed monomorphic ventricular tachycardia

• Rbbb (right bundle branch block)

ECHOCARDIOGRAPHY

• EF (EJECTION FRACTION): 10-15%

NORMAL EF IS 50-70%

• MILD TO MODERATE MR (MITRAL REGURGITATION)

CARDIAC ENZYME TEST

Troponin (protein) are released when the heart muscles has been damaged such as NSTEMI. The more damage the heart is, the greater amount of troponin t and I will be in blood.

normal in patient0.01

144

Patient’s troponin level

8/3/2016

CHEST X-RAY

• B/L LOWER ZONE CREPTS

• RIGHT SIDED INFILTRATE

PATIENT’S LAB REPOTSTests 6/3/2016 7/3/2016 8/3/2016 9/3/2016 Normal Level

Na 132 136 132 132 136-145

K 4.9 4.6 4.5 4.0 3.5-5.1 Normal

Cl 102 99 105 99 101-112

BIC 25.5 15.6 27.4 19.6 22-32

Cr 6.3 5.7 4.3 4.3 0.6-1.1

Mg 2.1 2.1 2.2 1.9 1.6-2.6 Normal

BUN 73 81 53 52 6-20

CONTINUE…tests 6/3/2016 7/3/2016 8/3/2016 9/3/2016 Normal LevelPT 14 19 19 10.9 9-14APTT 30.9 95 95 135 25-35

PLT 73 69 74 109 150-400

WBC 10.6 13.6 22.8 22.8 4-10

HCT 34.8 39.6 36.6 36.4 35.4-42.0 Normal

RBC 4.15 4.62 4.16 3.47 3.9-5.5 Normal

HCO3 15.7 17 14.8 15.9 20-31 Normal

Ca 6.5 7.5 7.5 9.5 8.6-10.2

CBC

INR 1.9 1.9 1.9 1.8 0.8-1.1

Trop-1 144 144 138 144.13 0.01NG/ML

PH 7.34 7.39 7.34 7.35-7.45 Normal

ABG’S RESULTPH 7.39

PcO2 30.00

PO2 204.80

HCO3 15.70

SO2 99.6%

S. Vancomycin level 0.10

ONGOING MONITORING BP OF THE PATIENTTime 7-3-2016 8-3-2016 9-3-2016

7:00 am 126/64mmHg 97/55mmHg 122/64mmHg

8:00 am 141/70mmHg 118/66mmHg 101/62mmHg

9:00 am 115/77mmHg 112/68mmHg 130/63mmHg

10:00 am 120/65mmHg 139/68mmHg 119/62mmHg

11:00 am 133/66mmHg 113/68mmHg 110/67mmHg

12:00 pm 122/64mmHg 127/58mmHg 129/73mmHg

1:00 pm 120/64mmHg 125/69mmHg 127/67mmHg

Time 7-3-2016 8-3-2016 9-3-2016

7:00 am 64/min 66/min 62/min

8:00 am 70/min 66/min 68/min

9:00 am 65/min 80/min 62/min

10:00 am 66/min 71/min 70/min

11:00 am 73/min 69/min 73/min

12:00 pm 64/min 62/min 67/min

1:00 pm 55/min 66/min 64/min

Ongoing pulse monitoring

Time 7-3-2016 8-3-2016 9-3-2016

7:00 am 20/min 23/min 21/min

8:00 am 20/min 18/min 20/min

9:00 am 18/min 22/min 21/min

10:00 am 22/min 19/min 18/min

11:00 am 20/min 18/min 20/min

12:00 pm 18/min 20/min 19/min

1:00 pm 24/min 20/min 20/min

Ongoing monitoring respiration

Time 7-3-2016 8-3-2016 9-3-2016

7:00 am 99% 97% 99%

8:00 am 98% 98% 98%

9:00 am 97% 97% 96%

10:00 am 98% 98% 99%

11:00 am 100% 97% 99%

12:00 pm 99% 96% 98%

1:00 pm 97% 98% 99%

Ongoing monitoring of oxygen saturation

Dates Intake/output

02/03/2016 790/52 Positive

03/03/2016 1000/37 Positive

04/03/2016 644/274 Positive

05/03/2016 1344/578 Positive

06/03/2016 954/1200 Negative

07/03/2016 972/3180 Negative

08/03/2016 1648/1370 Positive

Ongoing Monitoring Intake and output of the patient

Medical management

Shock (For the treatment of VT)

Bipap (Bi-level positive airway pressure)

Intubation (SOB)

Dialysis (Due to kidney failure)

Medication

MEDICATIONSIndication: GI ulcer, stomach acidity

Side effect: Nausea, vomiting, headache and stomach pain

Interventions: Assess GI system: bowel sounds every 8 hours, abdomen for pen swelling and appetite loss

Omeprazole

(proton pump

inhibitor)

Indications: Irregular heart beat

Side effect: pulmonary toxicity, hypersensitivity, pneumonitis and blurred vision

Interventions: Monitor BP carefully during and slow the infusion if significant hypotension occurs.

Amiodarone (anti

arrhythmic

drug)

Indication: Angina and Coronary artery spasm

Side effect: Headache

Interventions : Administer GTN with extreme caution to patient’s with hypotension or hypovolemia

GTN (Glycer

yl trinitrate

)

MEDICATIONSIndications: Unstable angina, NSTEMI, stroke and heart attack

Side effects: Headache, dizziness, nausea, constipation or diarrhea and increased bleeding

Interventions: administer analgesics if headache occur

Clopidogrel (anticoagula

nt)

Indications: Angina, MI and transient ischemic attack,

Side effects: stomach pain, heart burn, nausea and vomiting.

Interventions: Assess patient for bleeding, GI irritation.

Ascard (anticoagula

nt)

Indication: Iron deficiency

Side effects: abdominal cramps, diarrhea, rash, sleep disorder, irritability and nausea

Interventions: Encourage client to take folic acid daily.

Folic acid (Vit-B

complex)

MEDICATIONIndications: respiratory infection

Side effects: discoloration of teeth and photo toxicity

Interventions: Take medication with a full glass of water to prevent from esophageal ulceration

Doxycycline

(antibiotic)

Indication: Nosocomial infection

Side effects: Seizures, phlebitis

Interventions: Monitor periodically liver and kidney function.

Meropenem (anti-infective)

Indication: Stomach ulcer, metabolic acidosis

Side effects: Slow breathing, frequent urge to urinate, head ache nausea and weakness

Intervention: Assess the client fluid balance throughout the therapy which includes intake and output, edema, daily weight and lung sounds.

Sodium bicarbonate (anti-

ulcer agents)

MEDICATIONIndication: To decrease the production of LDL by blocking the action of enzyme in the liver..

Side effects: Muscles pain, tenderness, weakness, confusion, fever and weight gain.

Interventions: Monitor lipid levels after 2-3 weeks of initiation of the drug.

Atorvastatin calcium

(antilipemic agent)

Indications: use for fungal infections of stomach, intestine and mucous membrane

Side effects: mouth irritations, diarrhea, nausea, stomach upset

Interventions: Monitor oral cavity specially the tongue for signs of improvement.

Nystatin (antibiotic)

Indication: Germicidal mouth wash that reduces bacteria in the mouth

Side effects: tooth or tongue staining, dry mouth, increased tartar

Interventions: Advise to use the oral rinse bid for 30 seconds after brushing.Instruct to expectorate after rinsing and not to ingest

Chlorhexidine Mouth

wash (antimicrobi

al)

ASSESSMENT OF THE PATIENT

Date 07/03/2016 08/03/2016 09/03/2016

Orientation (GCS) 15/15 15/15 15/15

Head Hairs: dry, black and white, equal distributed, smooth scalp, no lesions and no infestations

Hairs: dry, black and white, equal distributed, smooth scalp, no lesions and no infestations

Hairs: dry, black, and white, equally distributed, smooth scalp, no lesions and no infestations

EYE (pupil checked) Pupil: 3mm (PERRA), Symmetrical Eyelashes: intact Conjunctiva: pink and moist

Pupil: 3mm (PERRA) symmetrical, Eyelashes: intact Conjunctiva: pink and moist

Pupil: 3mm (PERRA), symmetrical Eyelashes: intactConjunctiva: pink and moist

Nose Symmetrical, non tender, patency intact and hairy

Symmetrical, non tender, patency intact and hairy

Symmetrical, non tender, patency intact and hairy

Ear Hairy, wax present Hairy, wax present Hairy, wax present

Mouth Dry lips, buccal mucosa moist, 6 teeth absent, caries present

Dry lips, buccal mucosa moist, 6 teeth absent, caries present

Dry lips, buccal mucosa moist, 6 teeth absent, caries present

Date 07/03/2016 08/03/2016

Neck Active ROM, carotid pulse present Active ROM, carotid pulse present

Lymph nodePre auricularPost auricularOccipitalSubmaxillarySubmentalSuperior cervicalPosterior cervicalSupra clavicular

Non tender non palpableNon tender non palpableNon tender non palpableNon tender non palpableNon tender non palpableNon tender non palpableNon tender non palpableNon tender non palpable

Non tender non palpableNon tender non palpableNon tender non palpableNon tender non palpableNon tender non palpableNon tender non palpableNon tender non palpableNon tender non palpable

Continue…

Date 07/03/2016 08/03/2016 09/03/2016Respiratory Air entry bilaterally, crackle

sounds are presentAir entry bilaterally, crackle sounds are present

Air entry bilaterally, crackle sounds are present

Cardiac S1+S2 along with murmur sound S1+S2 along with murmur sound S1+S2 along with murmur sound

Gastro intestinal Dome shape, soft abdomen, Bowel sounds present (normal)

Dome shape, soft abdomen, Bowel sounds present (normal)

Dome shape, soft abdomen, Bowel sounds present (normal)

Genito urinary Foleys implanted Amber color Foleys implanted Amber color Foleys implanted Amber color

Skin: Color, temperature skin, turgor, integrity

BrownishWarmLooseintact

BrownishWarmLooseintact

BrownishWarmLooseintact

Continue…

Date 07/03/2016 08/03/2016 09/03/2016

Musculoskeletal No deformity No deformity No deformity

Bilateral vascular check Radial+1 +1

Radial+2 +2

Radial+2 +2

Peripheral edema No No no

Pain assessment No No No

Drainage bag no no No

Invasive lines 20g cannula(Left hand)06/13/2016

20g cannula(Left hand)06/13/2016

20g cannula(Left hand)06/13/2016

Continue…

FUNCTIONAL HEALTH PATTERNS

PATIENT’S BIOGRAPHIC DATA

Name: XYZ (Male) MR# 000-00-00 Dr. Name: Fateh Ali Tepu Sultan Age: 72 years Marital status: Married Religion: Islam Language: Urdu and English Occupation: Civil Engineer Diagnosis: VT (ventricular tachycardia) Allergies: Not Known Surgeries: CABG (2000) Date of Admission: 01/03/2016

HEALTH PERCEPTION/HEALTH MANAGEMENT PATTERN

General state of health (own description): “ sihat niyamaat he kisi insan ke pass agar sihat he to us insan ke pass sub kuch he “.

• No medication were taken at home.

• Immunization status was immunized\vaccinated.

• Family members were well aware regarding disease process.

• Patient was neat, clean and well oriented to time, person and place.

• Patient was previously treated for CHD and CABG was done in 2000 and admitted to AKU with present complain of chest pain and sob.

Nursing diagnosis: medication noncompliance r/t complex and prolonged therapy as evidence by recurrent diseases and attenent verbalization

ACTIVITY EXERCISE PATTERN• Reparatory rate: 25 breaths/min, irregular and shallow breaths, use of accessory muscles, breath sounds were present

chest expansion was bilateral and elliptical in shape and no cyanosis observed.

• Productive cough with large amount, mucus pooled was yellow and thick with no odor.

• Oxygen saturation was 98% via RA chest physiotherapy was done regularly with oral suctioning.

• In medication nebulizer was given to the patient.

• Nursing diagnosis

Ineffective airway clearance r/t pooling secretions as evidenced by rapid breaths and thick sputum.

CIRCULATIONTemperature was 36.5 degree centigrade, BP was 162/70 mm Hg &

pulse rate was 81 b/m, regular and +2 amplitude +1. Hommen's sign was negative.

Extremities were pale and warm .

Edema was negative.

Capillary refill was rapid and was +3 seconds.

JVP 4 cm no active complain of chest pain heart sounds along with murmur sounds.

EKG and other monitors were attached and no pace makers were in placed.

I/V cannula was on right arm which was 20 gage with heplock and CVP on left jugular

vain 1000 sip condition intact.

Special test for this pattern: echocardiograph, ECG and chest x-ray.

Nursing diagnose: alter comfort r/t chest pain

High risk for bleeding r/t low plt count

ACTIVITYAs patient was civil engineer so he used to go to the office daily from 7 am to 3:00 P.m. walk for half hour regularly and in hospital he was CBR initially for 4 DAYS and after treatment he was up to chair.

Energy level (at home): zero (independent) , at hospital: iv (dependent).

Rom: passive (assisted), no accessory devices were used, no amputation done side rails up no use comfort devices no cane and no walker.

Nursing diagnosis: Activity intolerance related to increase oxygen demand as evidence by patient verbalization.

COGNITIVE PERCEPTUAL PATTERN Patient was well oriented to place person and time with GCS 15\15, memory intact, clear speech and sensory status intact.

Patient fully verbalize pain and pain tolerance scale was 3\5.

C=character: Sharp and heavy

O=onset: 01/03/2016

L=location: Chest

D=duration: 06:00 AM to 9:00 AM

E=exacerbating: Mobility and activity

R=relieving: rest

A=associated: SOB and Gabrahat

Nursing diagnosis: Altered comfort i.e. Chest pain related to less oxygen supply to the heart as evidence by patient verbalization and facial expression.

NUTRITION METABOLIC PATTERN

Patient was 150 cm in height and of 60 kg weight.

Skin condition was intact ,loose turgor no lesions observed.

Mouth ulcers observed, some teeth’s were missing (26 present)

no use of dentures.

Self ability to feed no such restrictions, soft and low salt diet.

Patient lost 5 kg weight within last 6 months from 65 to 60 kg.

Electrolytes = Na : 136 k : 5.8 cl : 99 ca :

Nursing diagnosis; Impaired oral mucosa r/t lack of oral

hygiene and inadequate hydration as evidenced by xerostomia (dry mouth) .

risk for impaired skin integrity r/t CBR .

ELIMINATION PATTERN Abdomen: soft, bowel sounds and function: normal.

No accessory devices (colostomy or ileostomy bags) were present.

Bladder: soft, urine clear, Foley's was in placed.

Nursing diagnosis: (urinary output 250 cc \6 hours.)

SLEEP AND REST PATTERNAccording to the patient he use to sleep for 7 to 8 hours at night with good quality.

No afternoon naps as he was used to go to office.

No sleep related problems and no use of sleeping pills no use of sleeping aids.

In hospital patient was facing a bit problem in sleeping pattern due to hospital environment and sob.

Disturbed sleep pattern related to environmental changes(hospitalization)as evidence by patient verbalization.

SELF PERCEPTION/SELF CONCEPT PATTERN

• GOOD SELF ESTEEM PATIENT WAS TOTALLY SATISFIED WITH SELF.

• SATISFIED WITH BODY IMAGE.

• PATIENT VERBALIZE THAT( “ I AM VERY EMOTIONAL PERSON WITH VERY SENSITIVE MOOD” )

COPING-STRESS TOLERANCE PATTERNPatient was calm but anxious about the disease process.

Stressor/ major life changes : health of the client.

Good coping mechanism by support of family.

No use of alcohol/tobacco/pan/cigarette/drug.

Family was the support system of the client (wife, daughter, sons).

ROLE AND RELATIONSHIP PATTERN Pt. Was a member of extended family living in a flat.

Other significant members were wife, daughter and sons.

Communication pattern (decision making) was done self (client).

Financial support is the responsibility of the client.

Patient and family are well socialized.

Completely satisfied with family .

VALUE BELIEF PATTERN

Patient was satisfied with life and he had no complain .

At home he was doing religious practices regularly but in hospital he is unable to do so due to disease process .

No evidence of value belief conflict.

No current or anticipated needs for spiritual support.

RELEVANT DIAGNOSIS Diagnosis

Infective breathing

Alteration in comfort

Activity intolerance

Risk of bleeding

Difficulty in swallowing

Risk for infections

Rationales

Low oxygen supply

Increase demand of oxygen

Due to low oxygen supply

Due less platelets count

Because of mouth ulcer

Long hospitalization and low immune system

NURSING CARE PLANS (NCPS)

SHORTNESS OF BREATH

Assessmentsubjective:

Patient verbalized “that Muja saans lena ma masla ho

raha.Objective:

Use of accessory muscle.

Respiratory rate=30Oxygen

saturation=90%Rapid shallow

breathing.

DiagnosisIneffective breathing pattern r/t increase

oxygen demand and decrease oxygen

supply as evidence by patients low Spo2 and high

respiratory rate

GOALSHORT TERM;

At the end of my shift patients

respiratory rate will reduce from

30 to 25/mLONG TERM:At the end of

hospitalization patient will be

able to maintain normal respiration

i.e. 16 to 20

INTERVENTIONS:

Administer oxygen. Monitor vital sign specially RR and

Spo2 Apply Bipap and

assess oxygen saturation (spo2) in

every 30 mins. Nurse will demonstrate

/verbalize breathing techniques for the patients i.e. deep

breathing and coughing proper positioning

Suctioning as needed

Evaluation….Patient maintain

99% oxygen saturation, respiration 20/minutes.

Patient is stable an no use of

accessory muscles

CHEST PAIN

AssessmentSubjective:

Pain verbalized by patient

Pain scale = 7/10COLDERA

objective:Pupil dilationRestlessness

Facial expressionpulse=150/min

BP = 120/68mmhgRR = 30

DiaphoresisMaoming

Diagnose impaired

comfort r/t chest pain secondary to disease process as evidenced by

patient facial expressions and

verbalization.

GoalShort term goal:

By the end of morning shift

patients pain scale will be reduced

from 7 to 5.Long term goal: At

the end of hospitalization

patients pain scale will be reduced to

zero.

Interventions:Administer MONA

Perform 12 lead ECGAdminister analgesics Maintain bed rest with semi fowler positon

Use non pharmaceutical

techniques to reduce pain

(Back massage, deep breathing, mind

diversion therapy)

Evaluation..At the end patient pain

score was zero And vital signs were

normalNo active complain of

chest pain.

COLDERACharacter: sharpOnset: 29/2/2016

Location : Chest radiated to left shoulder

Duration: 6:00 Am and 9:00 am

Exacerbation: movementRelieve: Rest and decrease

mobilityAssociation: Gabrahat , SOB

MONAM: Morphine

(analgesic) O: Oxygen

N: Nitrates (vasodilators)

A : Anticoagulant

ACTIVITY INTOLERANCE

AssessmentSubjective:

Patient report for fatigue

And verbalized ie. “Muje kamzoori mehsoos horehe

hai”Objective:

Pt looks weak and pale

Heart rate = 150/minuteSpo2= 92%

Respiration = 30/minute

Diagnose

Activity intolerance r/t increase O2

demand as evidence patient verbalization

GoalShort :

At the end my shift pt will progress

mobility within bedLong term:

Pt will demonstrate increased tolerance

to activity by discharge

InterventionComplete

monitoring of v/s ( rate, rhythm and

quality of RR)Provide complete

bed rest and peaceful

environmentAssess nutritional need associated

with activity intolerance

Increase activity gradually

Oxygen therapy

EvaluationOur short

term goal was met but long

term goal remained

incomplete due to time limitation.

RISK FOR BLEEDING

Assessment• Subjective data:

patient verbalized: I am taking anticoagulant since 2000

• Attendant verbalize: My dad has poor wound healing.

• Objective data: • Platelet

count=50• Bruises on left

hand• Impaired liver

function• fatigue

Diagnosis• Risk for

bleeding r/t less platelet count as evidence by patient’s lab result (platelet=50)

Goals• Short term goal:

At the end of my shift all the preventive measures will be taken to prevent the patient from injuries and cuts.

• Long-term goal: At the end of hospitalization patient will have complete information about thrombocytopenia and safety measurements.

Interventions• Explain to patient

that he is at risk for bleeding due to thrombocytopenia.

• Instruct the patient to cautiously use sharp objects.

• Avoid IM and toothbrush

• In case of any injury apply pressure on the site of injury for 15-20 minutes.

• Check for bleeding from orifices or in urine and sputum.

Evaluation• Patient verbalize

that he would manage bleeding incase of any injury.

• Patient responded that he have enough knowledge to reduce risk for bleeding.

RISK FOR INFECTION

Assessment• Objective

data:• T= 38.1• Assess for

moisture and texture.

• Phlebitis• Low

immune system

• Blood culture report showed Acinetobacter,

Diagnosis • Risk for

infection related to compromised host defense secondary to intubation as evidence by age and cluster of diseases.

Goals• STG: after the

end of my shift patient will demonstrate proper technique of hand washing.

• LTG: at the time of discharge patient will be having complete knowledge about infection control, wound care and incision site care and health education.

Interventions• Apply universal

precautions.• Proper hygiene

care.• Give teaching

about infection control.

• Balanced diet • Assess for factors

which increase risk of infection.

• Apply aseptic techniques.

• Limit visitors.• Reduce length of

hospital stay to prevent from nosocomial infections.

• Observe clinical manifestations for infection.

Evaluation• Patient have

knowledge about infection control.

• Patient demonstrate proper hand washing and verbalize wound care and incision site care.

ALTERED NUTRITION PATTERNAssessment:• Assessment• Objective

data:• Weak

appearance

• Ulcers in mouth

• Subjective data:

• Patient verbalized: I have lost weight 5kg within last six months

• Patient complaint that he cannot take regular diet.

DiagnosisAltered nutrition

pattern that is less than body

requirement related to decrease oral

intake secondary to mouth ulcers

GoalShort term goal:

Patient will maintain healthy mucus membrane

by two days.Long term goal:At the time of

discharge patient will maintain an

adequate nutritional status and will be free from ulcers.

EvaluationPatient verbalize of improving mouth

ulcers. mouth’s mucus

improved.Patient is able to take

soft diet without any complain.

TEACHING PLANS

TEACHING PLANSAssessment Objective Contents Strategies Time Evaluation

Objective dateIHDMultiple cardiac interrelated problems

Define NSTEMI

Discuss causes of NSTEMI

Discuss about the warning signs of the disease

Partially blocked of one or more coronary artery

Coronary arteryOcclusionObesityTobaccoHTNHigh LDLLow LDLSedentary life style

Chest pain (radiate to back, jaw, neck and shoulder) dizziness lightheadednessNauseaVomitingpalpation

Discussion through pictures

Discussion through content

Verbally and pictorial explanation to patient and family

1 minute and 30 sec

2 minutes

2 minutes

Family understood by replying the questions asked

The family members verbalized all the warning signs

Teaching plan for NSTEMI

Assessment Objectives Contents Strategies Time Evaluation

Subjective data:On discussion patient’s family members said that they need proper teaching on disease process

Discuss further about the complication of the disease

Explain preventive measurements of the disease

Heart failureCardiogenic shockArrythmiasis

Medication compliance DASH diet maintaining a healthy weight controlling BPLowering LDL Avoid tobacco useExercise

Explanation

discussion

1min and 30 sec

1 minute

Family was satisfied with teaching

Continue…

Assessment Objectives Contents Strategies Time Evaluation

Objective date: Labs:PLT= 680,000

To give knowledge to patient and family about thrombocytopenia

Bleeding disorder due to less platelets count

Discussion 2 minutes

Family

Subjective data:During discussion patient’s family members verbalized that patient is on anticoagulants

Discuss preventive measures with thrombocypenia

Observe bleeding from orificesUse sharps very cautiouslyPrevent himself from injuries and cutNO IM no toothbrushApply direct pressure on injured area more than 15-20 minutes

Discussion

Pamphlets3 minutes

Verbalized Understanding

Teaching plan for thrombocytopenia

Assessment objectives Contents Strategies Time Evaluation

Objective:Cr # 6.3BUN# 78Peripheral edemaElectrolytes imbalance

Define acute kidney failure

Describe causes of kidney failure

Discuss sign and symptoms of AKI

Abrupt loss of kidney function where kidney fail to filter waste products from the blood

Poor perfusion to kidneyHTNAcute tubular necrosisSever or sudden dehydrationAcute nephritis syndromeInfections

Generalized swelling due to fluid overloadBlood in urineHTNBruising easily

Discussion

Explanation

Discussion

1 minute

2 minute

2 minute and 30 sec

Patient family members verbalized all the teachings which were given

Subjective:Pt was unaware about his disease process but the family was interested to know about disease process

Explain dialysis Life support treatment that uses a special machine to filter harmful wastes, salt and excess fluid from blood

Explanation 1 minute Patient’s family members were very satisfied with teaching

Teaching plan for Acute Kidney failure

Assessment Objectives Contents Strategies Time Evaluation

To give knowledge about the healthy diet

Teaching about activity and exercise

Diet includes: protein(egg fish chicken, milk , and milk products) potassium:( vegetables, beans, and fruits) and vitamins.Pt should avoid high sodium diet

Likely walking

Explanation

Brochure

Explanation

4 min

2 minut

Patient was satisfied with teaching methods

Recognize sign and symptoms to report

Compliance medication

Decrease urine outputSOBDrowsinessChest pain or pressure

Discussion

Explanation

1 min

1 min

Continue…

Assessment Objectives Contents Strategies Time Evaluation

Objective:Pt looks worried and anxiousAscites.jaundice

Know about liver failure.

Sign and symptoms of liver failure.

Inability of the liver to perform its normal synthetic and metabolic function as a part of normal physiology.

Yellowing of skin and eyesPain in upper abdomen and swelling,Nausea and vomiting, malaise, sleepiness and confusion.

Discussion through chart

Explanation

1 min 30 sec

2 min

Patient family members understood by replying the questions asked

Subjective:Attendants said they need proper teaching on disease process to avoid complication and balance diet towards the disease.

Explain prevention of liver failure.

Understand treatment of liver failure.

Avoid drinking alcoholMaintain healthy weightGood nutrition practiceAvoid hepatotoxic drugs or OVT drugs.

Intensive care unitFluid managementMonitors of metabolic parametersMaintenance of nutrition, drugs, lifestyle changeLiver transplantation.

ExplanationPamphlet

Discussionpamphlet

2 min

2 min

Teaching plan for liver failure

Assessment Objectives Content Strategies Time Evaluation

Objective:Reoccurrence of NSTEMI

Understand the importance of medication compliance

Understand the importance of regular follow ups

Medicine adherence is important to reduce the chance of reoccurrence of the disease process

Regular follow ups is necessary to see that whether the patient is going well or not.

Discussion

Explanation

2 minutes

Teaching helped family members and patient for gaining further information and they conveyed thanks

Subjective:Attendants verbalized that patient is not taking medicines regularly and avoiding follow ups

To give knowledge about balance diet to avoid further complication towards disease process

Guide for small exercise for healthy life

Everyone's bodies are different and require different amount and types nutrients according to disease process

Small and regular exercise is important to maintain healthy weight and to meets the demand of daily life

Explanation through chart

Discussion through demo

3 minutes

2 minutes

Teaching plan on medication compliance

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