Reflective Journaling

Pt name, AR, is 73 year old male. He came to the ED with complains of Shortness of

Breath and Bilateral Lower Extremity edema. Pt is diagnosed for Congestive heart

failure, CHF. He has history of DM and takes insulin for it. He is previous smokers and

has had left knee surgery. He is getting acute dialyisis to help get rid of the BLE

swelling.

Concept Map

Decreased Cardiac Output: Inadequate blood pumped by the heart to meet metabolic

demands of the body.

Related to

Altered myocardial contractility/inotropic changes

Alterations in rate, rhythm, electrical conduction

Structural changes

Evidenced by

Increased heart rate (tachycardia), dysrhythmias, ECG changes

Changes in BP (hypotension/hypertension)

Extra heart sounds (S3, S4)

Decreased urine output

Diminished peripheral pulses

Cool, ashen skin; diaphoresis

Orthopnea, crackles, JVD, liver engorgement, edema

Chest pain
Desired Outcomes

Patient will display vital signs within acceptable limits, dysrhythmias

absent/controlled, and no symptoms of failure (e.g., hemodynamic parameters

within acceptable limits, urinary output adequate).

Patient will report decreased episodes of dyspnea, angina.

Patient will Participate in activities that reduce cardiac workload.

Nursing Interventions

Auscultate apical pulse, assess heart rate, rhythm. Document dysrhythmia if telemetry is

available.

Rationale: Tachycardia is usually present to compensate for decreased ventricular

contractility.

1. Note heart sounds

Rationale: S1 and S2 may be weak because of diminished pumping action.

2. Palpate peripheral pulses.

Rationale: Decreased cardiac output may be reflected in diminished radial, popliteal,

dorsalis pedis, and post tibial pulses. Pulses may be fleeting or irregular to palpation.

3. Monitor BP.

Rationale: In early, moderate, or chronic HF, BP may be elevated because of increased

SVR. In advanced HF, the body may no longer be able to compensate, and profound

hypotension may occur.

 4. Inspect skin for pallor, cyanosis.

Rationale: Pallor is indicative of diminished peripheral perfusion secondary to

inadequate cardiac output, vasoconstriction, and anemia. Cyanosis may develop in

refractory HF. Dependent areas are often blue or mottled as venous congestion increases.

5. Monitor urine output, noting decreasing output and concentrated urine.

Rationale: Kidneys respond to reduced cardiac output by retaining water and sodium.

Urine output is usually decreased during the day because of fluid shifts into tissues but

may be increased at night because fluid returns to circulation when patient is recumbent.

Excess Fluid Volume: Increased isotonic fluid retention.

May be related to

Reduced glomerular filtration rate due to decreased cardiac output/increased

antidiuretic hormone (ADH) production, and sodium/water retention

Possibly evidenced by

Orthopnea, S3 heart sound

Oliguria, edema, JVD, positive hepatojugular reflex

Weight gain

Hypertension

Respiratory distress, abnormal breath sounds

Desired Outcomes
 Demonstrate stabilized fluid volume with balanced intake and output, breath

sounds clear/clearing, vital signs within acceptable range, stable weight, and

absence of edema.

Verbalize understanding of individual dietary/fluid restrictions.

Nursing Interventions

1. Monitor urine output, noting amount and color, as well as time of day when

diuresis occurs.

Rationale: Urine output may be scanty and concentrated (especially during the day)

because of reduced renal perfusion. Recumbency favors diuresis; therefore, urine output

may be increased at night and/or during bed rest

2. Weigh daily. Frequently monitor blood urea nitrogen, creatinine, and serum

potassium, sodium, chloride, and magnesium levels. ( Dialysis )

Rationale: Documents changes to edema in response to therapy. A gain of 5 lb

represents approximately 2 L of fluid. Conversely, diuretics can result in excessive fluid

shifts and weight loss.

3. Assess for distended neck and peripheral vessels. Inspect dependent body areas

for edema (check for pitting); note presence of generalized body edema. ( Dialysis )

Rationale: Excessive fluid retention may be manifested by venous engorgement and

edema formation. Peripheral edema begins in feet and ankles (or dependent areas) and

ascends as failure worsens. Pitting edema is generally obvious only after retention of at

least 10 lb of fluid. Increased vascular congestion (associated with RHF) eventually

results in systemic tissue edema.

Dialysis: Pt. is on acute dialysis due to Fluid retention and imbalance electrolytes. This

has also resulted in unstable Vital signs and irregular heart rate. Pt. is weighed before and

after dialysis to calculate the fluid taken off and also labs are done twice a day to make

sure that the Pt. creatnin and BUN level with its K+ and Na- levels are moving towards

normal.

4. Auscultate breath sounds, noting decreased and/or adventitious

sounds (crackles, wheezes). Note presence of increased dyspnea, tachypnea, orthopnea,

paroxysmal nocturnal dyspnea, persistent cough.

Rationale: Excess fluid volume often leads to pulmonary congestion. Symptoms of

pulmonary edema may reflect acute left-sided HF. RHFs respiratory symptoms

(dyspnea, cough, orthopnea) may have slower onset but are more difficult to

reverse.

Activity Intolerance: Insufficient physiologic or physiological energy to endure or

complete required or desired activity.

May be related to

Imbalance between oxygen supply/demand

Generalized weakness

Prolonged bed rest/immobility

Possibly evidenced by

Weakness, fatigue

Changes in vital signs, presence of dysrhythmias

Dyspnea

Pallor, diaphoresis
Desired Outcomes

Participate in desired activities; meet own self-care needs.

Achieve measurable increase in activity tolerance, evidenced by reduced fatigue

and weakness and by vital signs within acceptable limits during activity.

Nursing Interventions

1. Check vital signs before and immediately after activity, especially if patient is

receiving vasodilators, diuretics, or beta-blockers.

Rationale: Orthostatic hypotension can occur with activity because of medication effect

(vasodilation), fluid shifts (diuresis), or compromised cardiac pumping function.

2. Document cardiopulmonary response to activity. Note tachycardia,

dysrhythmias, dyspnea, diaphoresis, pallor.

Rationale: Compromised myocardium and/or inability to increase stroke volume during

activity may cause an immediate increase in heart rate and oxygen demands, thereby

aggravating weakness and fatigue.

3. Implement graded cardiac rehabilitation program.

Rationale: Strengthens and improves cardiac function under stress, if cardiac

dysfunction is not irreversible. Gradual increase in activity avoids excessive myocardial

workload and oxygen consumption.

4. Assist patient with ROM exercises. Check regularly for calf pain and tenderness.

Rationale: To prevent deep vein thrombosis due to vascular congestion.

Risk for Impaired Gas Exchange: At risk for excess or deficit in oxygenation and/or

carbon dioxide elimination at the alveolar-capillary membrane.

Risk factors may include

Alveolar-capillary membrane changes, e.g., fluid collection/shifts into interstitial

space/alveoli

Desired Outcomes

Demonstrate adequate ventilation and oxygenation of tissues by ABGs/ oximetry

within patients normal ranges and free of symptoms of respiratory distress.

Participate in treatment regimen within level of ability/situation.

Nursing Interventions

1. Auscultate breath sounds, noting crackles, wheezes.

Rationale: Reveals presence of pulmonary congestion and collection of secretions,

indicating need for further intervention.

2. Instruct patient in effective coughing, deep breathing

Rationale: Clears airways and facilitates oxygen delivery.

3. Encourage frequent position changes.

Rationale: Helps prevent atelectasis and pneumonia.

4. Maintain chair or bed rest, with head of bed elevated 2030 degrees, semi-

Fowlers position. Support arms with pillows.

Rationale: Reduces oxygen demands and promotes maximal lung inflation.

5. Place patient in Fowlers position and give supplemental oxygen.

Rationale: To help patient breath more easily and promote maximum chest expansion.

6. Graph graph serial ABGs, pulse oximetry.

Rationale: Hypoxemia can be severe during pulmonary edema. Compensatory changes

are usually present in chronic HF. Note: In patients with abnormal cardiac index, research

suggests pulse oximeter measurements may exceed actual oxygen saturation by up to 7%.

Objectives that were met:

Hemodialysis separates solutes by differential diffusion through a cellophane

membrane placed between the blood and dialysate solution, in an external receptacle.

Blood is shunted through an artificial kidney (dialyzer) for the removal of excess fluid

and toxins and then returned to the venous circulation. Because the blood must actually

pass out of the body into a dialysis machine, hemodialysis requires an access route to the

blood supply by an arteriovenous fistula or cannula or by a bovine or synthetic graft. For

acute dialysis we use an IJ catheters. Hemodialysis is a fast and efficient method of

removing urea and other toxic products. It is usually performed three times per week for

four hours and can be done in a hospital, outpatient dialysis center, or at home.

Hemodialysis has 3 goals

1. Monitor the vital sign

2. Fluid Volume balance

3. Correction of blood serum and plasma.

We monitor the vital sign, Arterial and Venous peruse and every 15 minutes. It helps us

in maintaining constantly maintain fluid balance as evidenced by stable/appropriate

weight and vital signs, good skin turgor, moist mucous membranes, absence of bleeding.

As the Pt. BP fluctuated we were able to help the Pt. by putting his head down and feet

up. We did one on one Pt. management. We had IV saline ready to give in case of drastic
drop in the BP. It help with there Hypotension, tachycardia, falling hemodynamic

pressures that suggest volume depletion.

We measure accurate I&Os in dialysis. It aids in evaluating fluid status, especially

when compared with weight. Urine output is an inaccurate evaluation of renal function

in dialysis patients. Some individuals have water output with little renal clearance of

toxins, whereas others have oliguria or anuria. That is why we weigh them before and

after the dialyisis. We also have doctors orders how much fluid to take off and the speed

we need to use to take off the fluid and correction of the blood serum and plasma.

Evidence-based article

Use of the Trendelenburg position by critical care nurses:

Trendelenburg survey.

BACKGROUND:

Little evidence indicates that changing a patient's body position to the

Trendelenburg (head lower than feet) or the modified Trendelenburg (only the legs

elevated) position significantly improves blood pressure or low cardiac output. This

intervention is still used and is often the first measure implemented for treatment of

hypotension.

OBJECTIVES:

The purpose of this research was to assess the degree of use of Trendelenburg

positions by critical care nurses, the clinical uses of these positions, and the sources of

knowledge and beliefs of nurses about the efficacy of the positions.

 METHOD:

A survey was mailed to 1000 nurses whose names were randomly selected from the the

membership list of the American Association of Critical-Care Nurses.

RESULTS

The return rate was 49.4%. Ninety-nine percent of the respondents had used the

Trendelenburg position, and 80% had used the modified Trendelenburg position, mostly

for treatment of hypotension. Most used this intervention as an independent nursing

action, and most learned about these positions from their nursing education, nurse

colleagues, supervisors, and physicians. The Trendelenburg position was used for many

nonemergent reasons; the most frequent use was for insertion of central IV catheters.

Although 80% of the respondents believed that use of the Trendelenburg position

improves hypotension almost always or sometimes, many respondents recognized several

adverse effects associated with use of this position.

DISCUSSION AND CONCLUSIONS:

The results provide evidence that tradition-based therapy still underlies some

interventions used in the care of critically ill patients and that some nurses may be relying

on an outdated knowledge base that is not supported by the current literature.

How does this make a difference in your practice ?

This article reinforces my practice. At the dialysis unit I have seen it done many

time with different Pt. with positive results. So I will adopt this as apart of my first line of

intervention for low BP. I think it is easily done, does not need a doctors orders and helps

the Pt. feel better without any side effects.

How does this contribute to your readiness for leadership development and

professional nursing practice?

Every nursing department is composed of individuals serving in the variety of

roles

required to meet clients needs. The fact that there are RNs, LPNs, and CNAs, who are

assigned to work in a particular area, does not mean that this group functions as a team.

Nursing staff can be fragmented and in different directions, or they can have a defined

focus and work together toward goals. The level of success achieved is frequently based

on the strength or weakness the nurse leader and this leaders ability to inspire others.

If nurses in my department believe in non pharmalogical interventions, I would

make sure that their practices match the hospital practices. I will look up evidence-based

studies to support the practice on the floor and have teaching opportunities available for

the staff members on how to use these interventions properly and effectively with

positive results. One of the most important realizations that can be grasped by a nurse

leader is that no one person can achieve significant outcomes alone. Behind every

successful person is a team of individuals who support their leader and pave the way for

success through combined efforts. This type of leadership displays the leaders strengths,

and brings the team together to provide best result in great environment.
 References

Jarquin, Bridges N. (2011) Department of Health Restoration, School of Nursing, West

Virginia University,Morgantown, USA

Frandsen, Betty. (2014). Nursing Leadership, management and leadership style.

Nurselabs.com