Reflection: Can’t Find a Nursing Diagnosis!

While receiving report about my patient, we’ll call her P.V., from the nurse the other day,  I gathered this information: “She’s a 90 year old female with CAD, mild hypertension and high cholesterol. She presented to the ED from her assisted living facility with chest and abdominal pain. She had a stent placed in 2004 for CAD and suffers from angina.” So, prior to my assessment, I organized the questions in my head that I’d ask her about her social history and had the perfect idea of how she might present physically. I assumed she might be a smoker, possibly enjoy a few evening “beverages”, and that she may be obese. I knew I’d ask her about her daily activity and if she exercises, and I was pretty sure I already knew the answer to that question. I thought her legs may feel cold and look shiny. I was certain I’d get to hear a dysrhythmia, an S3 or an S4. I figured she may not have the energy to ambulate the halls considering her heart condition and her age. Perhaps she’d be anxious, was another thought that crossed my mind.

 

As I walked into P.V.’s room to introduce myself and start the assessment, I met the sweetest and most beautiful 90 year old woman. She looked up with a smile and said “good morning”. I explained to her that I would be her student nurse for the day then asked if I could check her vital signs. She consented with the statement, “ Whatever you need to do dear, go right ahead”. Her BP confirmed mild hypertension at 131/73, but that was prior to meds. The rest of her vital signs were normal, with an O2 of 99% on room air, respirations at 18 and pulse at 63. I went on to do my assessment and found that her apical pulse was 83, and her radial and pedal pulses about 75. Her lungs were clear and I did hear an S4 heart sound. She had fantastic bowel sounds. I checked for capillary refill, and that was normal as well. Then I went on to assess her extremities. They were warm, non edematous and all extremities had great strength. Her pedal pulses were easily felt and I counted her pulse to be right near her apical pulse. Great circulation lady! She was religious about wearing her sequential compression devices and taking her medications as well.

 

After the physical assessment I decided to ask her some questions to get a better idea of her history and the reason for her stay. I started with her social history. She’s never smoked a day in her life and alcohol or even an occasional glass of wine does not interest her. She is very active and walks the mall everyday for at least 30 minutes, but more then that she’s always been active because she tells me that, “you have no time to sit when raising 5 kids”. She eats fruits and vegetables everyday and tries to maintain a healthy diet, but does admit that she loves food and perhaps she didn’t always consider cholesterol in her past, while cooking for a large family. Then she goes on to tell me that her father died at 71 of coronary artery disease.

 

So, family history and some slightly poor food choices (or at least according to the patients report) are the two main factors that I feel have caused her mild hypertension and cholesterol levels, her history of atherosclerosis and CAD and  the stent placement that occurred in 2004. This vivacious, energetic and determined woman, with beautiful legs, was not what I envisioned in my head prior to walking in to meet her that morning. The fact that she eats well, exercises regularly and does not smoke or drink are all contributing factors to her great health, despite the fact that on paper she may not appear heart healthy.

 

One of the hardest things I encountered while taking care of this patient was figuring out a nursing diagnosis for her. The very short lived pain that she originally presented to the ED with was gone within hours of admission and had never returned, so Acute Pain was out. She ambulated the halls with me two times (without my hand or a walker) and sat in the chair independently for most of the shift, so activity tolerance was scratched off the list immediately. She had great pulses and perfusion to all extremities, so I couldn’t use Ineffective Tissue Perfusion. Her bowel movements were regular and she stated that she had no constipation. Her heart and lung sounds were good and capillary refill ❤ seconds with no edema, so Decreased Cardiac Output was also not the best option. Here’s how my report paper looked:

Acute Pain

Ineffective Tissue Perfusion

Constipation

Decreased Cardiac Output

 

After some thought, I felt that my only options were to go with a “Readiness for Enhanced…” or “ Risk for…” diagnosis.

My diagnosis became: Risk for Decreased Cardiac Tissue Perfusion. This diagnosis came after much flipping through my Nursing Diagnosis Handbook and looking at her medical diagnosis of CAD, hypertension and atherosclerosis, which led me to the appropriate nursing diagnosis. The risk factors for decreased cardiac tissue perfusion consist of hypertension, hyperlipidemia and family history of CAD, all of which matched her history, so I went with it. I  had finally found my nursing diagnosis! What’s interesting, is that prior to meeting her, reviewing her history and learning about her lifestyle, I thought to myself, “oh, I won’t have trouble coming up with a nursing diagnosis at all, I could think of a million diagnoses for a patient with CAD, atherosclerosis or mild hypertension.”  My patient was everything opposite of what I thought she’d be.

 

This was a great learning experience because it reminded me, once again, that every patient is completely different. Even though disease processes present with pretty much the same certain symptoms, each patient presents differently based on their make up,  lifestyle choices, family history,  social history, past medical history, motivation and mindset. We are complex beings, and each person unique in his or her own way. My instructor Mrs. Stein and I have discussed (several times) in clinical’s that each case or client is individual and as a nurse individualized care is so important. I’m starting to see this each and every time I interact with a new patient. It’s so important to really know your patient beyond the computerized chart, because asking questions, assessing and monitoring tells the nurse much more then just whats on paper. I now know this to be true after my encounter with the amazing P.V.

 

I can only hope and pray that I’m as active and healthy with such beautiful legs as my 90 year old client P.V.  Even though her family history of CAD and her sometimes extra fondness for food caused her to experience cardiac complications, she made smart choices elsewhere by exercising, changing her eating habits and abstaining from alcohol and cigarettes. I truly feel this is the reason for her terrific age, beautiful legs, incredible energy and decreased cardiac complications. I will never assume that I know what a mildly hypertensive CAD patient looks like again!

 

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