Christina Rafano shows how to write nursing diagnoses for left-sided heart failure using NANDA terminology. Each diagnosis needs three parts: the label, a related-to factor like reduced contractility, and signs and symptoms like dyspnea and crackles. Tailor each one to your patient's actual assessment findings to earn full points.
Hey there my friend. My name is Christina Rafano with nursingsos.com and today in this video we are walking through nursing diagnosis or left sided heart failure. This is a disorder for med surge that you are going to see all the time at clinical. You're going to talk about it a lot in nursing school, you're going to be tested on it a lot and you're going to have to write a lot of care plans on it. So hit that subscribe button and click the notification bell and let's dive in. So I'm actually taking our care plan straight out of our care plan database inside the nursing SOS membership community. So if you want access to my entire care plan database, my concept map database, all my study guides and cheat sheets, definitely check out the nmc. You are going to love it. I'll put the link down below in the description for you to check out the details for that. So for left sided heart failure, what's happening here basically is the heart is really struggling to pump blood forward into the body. So that left side of the heart pumps blood to the rest of the body. Okay, so there's a really key difference here between left sided heart failure and right sided heart failure. Left sided heart failure pumps blood to the body. So we'll see as we go through this care plan. You'll see it's specific to blood moving forward into the system. We'll walk through that. So some possible nursing diagnoses that you could use for left sided heart failure are things like decreased cardiac output because the heart's pumping blood into the body. You have a decrease in cardiac output because of this disorder. Ineffective tissue perfusion. The tissues just are not getting the blood that they need to function. Excessive fluid volume in the body because the heart just can't pump. So it's going to kind of that you'll have see swelling or edema in the patient's body because all that fluid is just getting stagnated in the body because the heart can't pump it forward in the system. And then activity intolerance, if a patient's heart is really struggling to pump that blood, they're not going to be able to do the activities that they normally would be able to because the organs are not being perfused. So activity intolerance could be a good nursing diagnosis as well. And remember my friend, your nursing diagnosis is standardized. You don't come up with these by yourself. They are actually a you pull from a standardized list from the NANDA nursing diagnosis list. You can find that in your textbooks or through your nursing school, but you actually choose from that list, so you don't have to make those up. All you need to do is pick what best nursing diagnosis fits your patient from that standardized list. Now, I really want to make sure that as you're writing your nursing diagnosis and writing your care plan, that you are being as specific to your patient as possible. In order to get the highest points possible on your care plan in nursing school, it's got to be specific to your patient, your clinical instructor, your nursing instructor. They will know if you're just pulling stuff out of thin air, I promise you. So make sure that you've actually assessed your patient, that you know what's going on with your patient and that your care plan is specific to your patient. You're not just doing like general things because your nursing instructor will catch on to that and you will lose points. So don't do that. Okay? Be as specific to your patient as you can. So now the second part of your nursing diagnosis, the first part is actually the Nanda nursing diagnosis part. The second part is what we call the related to or related to factor. Now this is really what I like to see in care plans is more like the pathophysiology, this is the why behind what's happening. So why is this heart failure happening? What is heart failure? What is causing this problem for the patient? So with your clinical instructor, with your nursing instructor, you can show them that you actually really understand what is going on with your patient, that through this related to factor related to section in your nursing diagnosis. Because this is the pathophysiology, this is a lot more critical thinking. So think through what's actually happening with your patient with left sided heart failure that's causing all these problems. So here you could use things like structural changes to the cardiac muscle, changes in cardiac contractility so the heart just can't contract. It is a decrease in that contractility, reduced glomerul, glomerular filtration rate that could be caused because the heart cannot perfuse the kidneys as well as it should. So the kidneys are going to reduce their function. And then with that decreased gfr, that glomerular filtration rate, then you could see that excess fluid volume because the kidneys are just holding on to more fluid, they're not going to be doing their job as well. So that could be an interesting one to write in your care plan if that's happening with your patient. That would really show your nursing instructor that, hey, like, I know what I'M talking about here. The heart's impacting the kidneys and the kidneys are leading to this increased fluid volume. So that's a really good way to put all the concepts together and critically think about it. Or medication side effects maybe that those kidneys just aren't functioning well so it's causing all of this like decreased cardiac output or activity intolerance. Or there's maybe some medication side effects that is causing the heart to have issues to perfuse the rest of the body. So the those could all be good related to factors. Now the as evidenced by section of your care plan of your nursing diagnosis is the signs and symptoms. So again we want to make these specific to your patient as possible. So what are the signs and symptoms that your specific patient is displaying? So when you go and assess your patient at clinical what do you see with this patient? Do they have dyspnea? Is there crackles in their lungs because of all that fluid buildup? Do they have tachycardia? Is the heart heart rate elevated? Are they fatigued? Do they have that activity intolerance? Are they having a hard time doing their activities of daily living? Their ADL's? Do they have a cough? Do they had have altered cardiac function? Have there been any testing? Do they have any EKG results that are abnormal? So you would want to write down those signs and symptoms that are specific to your patient in this as evidenced by the AEB section of your nursing diagnosis. Now we want to show know your nursing instructor, right, that you actually assessed your patient and you know what you're talking about. So again, don't pull things out of thin air. We're not going to do that. Be specific to your patient like we talked about. You've got those three parts to it. The nursing diagnosis, the related to and the as evidenced by. But that can be pretty tricky to write, especially when you're writing different care plans for different patients and for different disorders. So definitely check out this video here where I walk you through some step by step how to write a perfect nursing diagnosis. I think that video is going to be so so helpful for you as you write all your care plans in nursing school. And of course, if you liked this video, hit that like button. Write love in the comments below because that is what we do around here. We love love, love writing love in the comments. And as always my friend, go become the nurse that God created only you to be. And I will see you over there in that next video.
