Develop Care Plan Question & Answer Guide (With Explanation)

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Original Question

Develop a care plan with 3 nursing diagnosis for the patient Simulation Case study: Clinical Management of a patient with persistent Atrial Fibrillation Patient W is a woman, 58 years of age, who is admitted to the unit with bradycardia and near syncope. She says that this morning she had been grocery shopping, became very dizzy, and nearly passed out. On admission assessment, her blood pressure is 116/74 mm Hg, and her heart rate is 48 bpm and irregular. Her respirations are even and easy at a rate of 20 breaths per minute. Her oxygen saturation on room air is 99%. Peripheral pulses are slightly diminished. Lung fields are clear to auscultation. Patient W is placed on continuous telemetry monitoring, and a 12-lead ECG is obtained. The ECG shows that her underlying rhythm is atrial fibrillation with a slow ventricular response. Patient W says that she has had atrial fibrillation for several months. Initially, her heart rate had been controlled on oral antiarrhythmic medications. However, over the last month, she has been experiencing increasing episodes of palpitations and a rapid heart rate. Her medication had been increased, but she developed hypotension and a slow heart rate on the increased dose. A few days prior to her admission, her oral antiarrhythmic medication was changed. On the new medication, she has not had any prolonged episodes of a rapid heart rate but experienced some “dizzy spells.” Comments and rationale: Lack of adequate rate control coupled with development of serious side effects such as bradycardia, hypotension, and syncope with multiple oral agents are indications that oral antiarrhythmic therapy is not effective in managing the patient’s atrial fibrillation. Other options include pharmacologic cardioversion, electrical cardioversion, radiofrequency ablation with or without pacemaker insertion, or continuation of oral medications with insertion of a demand pacemaker to treat symptomatic bradycardia. Laboratory tests are ordered, including a complete blood count, serum electrolytes, renal and hepatic function tests, chest x-ray, urinalysis, and PT/INR. A peripheral IV access is established. Continuous telemetry monitoring is maintained, and Patient W’s vital signs are monitored every four hours. Her heart rate remains between 48 and 52 bpm. Patient W’s oral antiarrhythmic medication is discontinued. Analysis of Patient W’s ECG shows that her QTc is 580 msec. The therapeutic options of electrical cardioversion, radiofrequency ablation, and continued oral antiarrhythmic therapy with insertion of a demand pacemaker are discussed with the patient. The patient expresses reluctance to undergo pacemaker insertion at this time. With the patient’s agreement, she is scheduled for electrical cardioversion. Patient W expresses the understanding that pacemaker insertion or ablation with pacemaker insertion might still be required if cardioversion is unsuccessful or if she becomes symptomatic on therapy to maintain sinus rhythm following successful cardioversion. Comments and rationale: Laboratory tests such as a complete blood count and serum electrolytes are ordered to rule out any abnormal findings (e.g., anemia, hypokalemia, hypomagnesemia) that may make management of atrial fibrillation more difficult. Due to Patient W’s continued bradycardia, her oral antiarrhythmic medication is discontinued. Her QTc interval is significantly prolonged. Because Patient W has developed bradycardia and a prolonged QTc interval, she is not a candidate for pharmacologic cardioversion. Patient W’s complete blood count, renal and hepatic function studies, and urinalysis come back within normal limits. Her serum electrolytes show hypokalemia but a normal serum magnesium level. IV potassium replacement is given, and a repeat potassium level returns within normal limits. Patient W’s INR comes back at 2.7. Her usual warfarin dose is continued. A review of her outpatient laboratory results shows that her INR has been maintained between 2.6 and 3.1 for more than six weeks. Comments and rationale: Hypokalemia may contribute to the continuation of atrial fibrillation. It should be corrected prior to electrical cardioversion or other intervention. Because of the risk of thromboembolic complications caused by left atrial thrombi for persons with atrial fibrillation of more than 48 hours duration, anticoagulation with warfarin is indicated. National standards require anticoagulation for at least three weeks prior to cardioversion. The therapeutic target for warfarin is an INR of 2.0-3.0. Patient W is kept NPO for six hours prior to the cardioversion. She is taken to the preoperative area prior to the procedure and sedated with IV medications. Continuous ECG, blood pressure, and oxygen saturation monitoring is initiated. The cardioverter/defibrillator is set for a low-energy, synchronized shock. The initial shock is ineffective in restoring sinus rhythm. A second, slightly higher energy shock is effective. ECG monitoring shows Patient W is now in normal sinus rhythm at a rate of 62 bpm. Her vital signs are monitored closely until she wakes up from the sedation. Patient W is returned to her room. Continuous telemetry monitoring is continued. Comments and rationale: Electrical cardioversion is a painful procedure; sedation or general anesthesia is required. Because of the risks associated with sedation/anesthesia, and the risk that the patient may go into ventricular fibrillation from an electrical shock, cardioversion should be performed in a setting where emergency equipment for intubation and management of cardiac arrest is readily available. Patient W remains in normal sinus rhythm at an acceptable rate in the immediate period post cardioversion. Her blood pressure is stable, and her dizzy spells do not recur. She is discharged on a low-dose oral antiarrhythmic and warfarin. Patient W is instructed to notify a physician if she experiences palpitations, dizziness, or near-fainting spells. Comments and rationale: Oral antiarrhythmic therapy is generally required to maintain normal sinus rhythm following successful cardioversion. Although Patient W had been unable to take higher dose oral antiarrhythmics, she was able to tolerate low-dose therapy. It is likely that Patient W will experience short episodes of atrial fibrillation. However, therapy is considered successful if these episodes are brief, do not cause debilitating symptoms, and resolve without additional treatment. National standards recommend that anticoagulation therapy be continued for at least four weeks following cardioversion.

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