acute coronary syndrom
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b) Nursing Care Plans Problem#1: Acute Pain Cues Nursing Diagnosis Scientific Explanation Objectives Nursing Interventions Rationale Evaluation S> “Masakit ku salu”, as verbalized by the pt. O> The patient may manifest: - tachycardia - tachypnea - sleep disturbance - facial grimaces - irritability >The patient manifested: - with oxygen hooked via nasal cannula regulated at 2 lpm - with condomcatheter attached to urine bag - continuous Acute Pain related to increased lactic acid production secondary to decreased blood and oxygen supply to myocardium Acute Pain is the prioritized problem because it suggests ischemia which is very fatal. In acute myocardial infarction more commonly known as heart attack, a medical condition that occurs when the blood supply to a part of the heart is interrupted, most commonly due to rupture of a vulnerable plaque. The resulting ischemia or oxygen shortage causes damage Short term: After 4 hours of NI, the patient will report relief of pain. Long term: After 2 days of NI, the patient will demonstrate use of relaxation techniques and divertional activities as indicated for individual situation. >Establish rapport >Assess patient’s condition >Monitor VS >Perform a comprehensive assessment of pain >Assess respirations, BP and heart rate with each episodes of chest pain. >Observe nonverbal cues >to gain trust and cooperation >to determine s/sx >to obtain baseline data >to determine precipitating factor/s > respirations may be increased as a result of pain and associate anxiety. >observations may/may not be congruent with Short term: After 4 hours of NI, the patient shall have verbalized methods that provide relief. Long term: After 2 days of NI, the patient shall have demonstrated use of relaxation techniques and divertional activities as indicated for individual situation. 134
description
acute coronary syndrome
Transcript of acute coronary syndrom
b) Nursing Care Plans
Problem#1: Acute Pain
Cues Nursing DiagnosisScientific
ExplanationObjectives
Nursing Interventions
Rationale Evaluation
S> “Masakit ku salu”, as verbalized by the pt.
O> The patient may manifest:- tachycardia- tachypnea- sleep disturbance- facial grimaces- irritability
>The patient manifested:- with oxygen hooked via nasal cannula regulated at 2 lpm- with condomcatheter attached to urine bag- continuous cardiac monitoring
Acute Pain related to increased lactic acid production secondary to decreased blood and oxygen supply to myocardium
Acute Pain is the prioritized problem because it suggests ischemia which is very fatal. In acute myocardial infarction more commonly known as heart attack, a medical condition that occurs when the blood supply to a part of the heart is interrupted, most commonly due to rupture of a vulnerable plaque. The resulting ischemia or oxygen shortage causes damage and potential death of heart tissue. Because of decreased blood and oxygen supply to myocardium, shifting from aerobic to anaerobic metabolism happens thus there is an increase in lactic acid production causing irritation to
Short term:After 4 hours of NI, the patient will report relief of pain.
Long term: After 2 days of NI, the patient will demonstrate use of relaxation techniques and divertional activities as indicated for individual situation.
>Establish rapport
>Assess patient’s condition
>Monitor VS
>Perform a comprehensive assessment of pain
>Assess respirations, BP and heart rate with each episodes of chest pain.
>Observe nonverbal cues
>Provide comfort measures such as back rub
>Provide adequate rest periods
>to gain trust and cooperation
>to determine s/sx
>to obtain baseline data
>to determine precipitating factor/s
> respirations may be increased as a result of pain and associate anxiety.
>observations may/may not be congruent with verbal reports indicating need for further evaluation
>to provide non pharmacological measures of relieving pain
>to prevent fatigue
Short term:After 4 hours of NI, the patient shall have verbalized methods that provide relief.
Long term:After 2 days of NI, the patient shall have demonstrated use of relaxation techniques and divertional activities as indicated for individual situation.
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the heart muscle. This mechanism causes a feeling of pain which may activate the sympathetic nervous system thus causing tachypnea and tachycardia as a response. Due to the uncomfortable sensation, the patient may be seen with facial grimaces and irritability.
>Maintain bed rest during pain, with position of comfort, maintain relaxing environment to promote calmness.
>Prepare for the administration of medications, and monitor response to drug therapy. Notify physician if pain does not abate.
>Review ways to lessen pain
>Provide for individualized physical therapy/exercise programs that can be continued by the client when discharged
>Discuss with SO(s) ways in which they can assist client and reduce precipitating factors that may cause or increase pain
>Instruct patient/family in
and promote relaxation
>to reduce oxygen consumption and demand, to reduce competing stimuli and reduces anxiety
>pain control is a priority, as it indicates ischemia
>to promote wellness
>promotes active, not passive role
>to promote wellness
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medication effects, side-effects, contraindications and symptoms to report
> to promote knowledge and compliance with therapeutic regimen and to alleviate fear of unknown
Problem#2: Ineffective airway clearance
Cues Nursing DiagnosisScientific
ExplanationObjectives
Nursing Interventions
Rationale Evaluation
S> The patient may verbalize:- dyspnea
O> The patient manifested:- productive cough- fuzziness of the lung markings in both lungs- with oxygen hooked via nasal cannula regulated at 2 lpm- with condom catheter attached to urine bag- continuous cardiac monitoring
> The patient may manifest:- changes in respiratory rate or rhythm- diminished or adventitious breath
Ineffective airway clearance r/t retained tracheobronchial secretions AEB presence of productive cough
Pneumonia is an infectious disease characterized by inflammatory processes affecting the lung parenchyma. The invading organism causes symptoms, in part, by provoking an overly exuberant immune response in the lungs.Mucus production is increased which plugs the airway thus further compromising the airway clearance of the patient. This event may bring about cyanosis. In order to compensate, the patient may breathe rapidly in order to bring in more oxygen
Short term:After 4 hours of NI, the patient will demonstrate behaviors to improve or maintain airway patency.
Long term: After 4 days of NI, the patient will demonstrate absence/reduction of congestion with breath sounds clear, respirations noiseless and improved oxygen exchange.
>Establish rapport
>Assess patient’s condition
>Monitor VS
>Auscultate breath sounds
>Assess respiratory movements and use of accessory muscles
>Observe for signs and symptoms of infection
>Monitor chest radiograph reports
>to gain trust and cooperation
>to determine s/sx
>to obtain baseline data
> to note presence of adventitious breath sounds
> use of accessory muscles to breathe indicates and abnormal increase in work of breathing
> to identify infectious process and promote timely interventions
>to monitor the severity of the
Short term:After 4 hours of NI, the patient shall have verbalized methods that provide relief.
Long term:After 2 days of NI, the patient shall have demonstrated use of relaxation techniques and divertional activities as indicated for individual situation.
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sounds- cyanosis
thus manifesting changes in respiratory rate or rhythm.
>Use positioning by placing on a semi-high fowler’s position
>Elevate head of bed or change position every 2 hours and prn
>Maintain adequate hydration when possible
> Perform nebulization and CPT as indicated
>Institute suctioning as needed
>Use naso-pharyngeal / oro- pharyngeal airway as needed
>Administer medication as prescribed
disease
>to facilitate lung expansion
> to take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage or ventilation to different lung segments
>to aid in the mobilization of secretions
>to loosen secretions
> to clear airway when secretions are blocking the airway
> to have patent airway through artificial means
>to provide pharmacological management to treat condition
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>Administer analgesics as prescribed
>Refer to appropriate support groups
>to maximize cough when pain is inhibiting effort
> to promote continuity of care
Problem#3: Impaired Gas Exchange
Cues Nursing DiagnosisScientific
ExplanationObjectives
Nursing Interventions
Rationale Evaluation
S> The patient may verbalize:- dyspnea
O> The patient manifested:- productive cough- fuzziness of the lung markings in both lungs- with oxygen hooked via nasal cannula regulated at 2 lpm- with condom catheter attached to urine bag- continuous cardiac monitoring
> The patient may manifest:- confusion- lethargy- abnormal ABG’s- cyanosis
Impaired Gas Exchange r/t collection of secretions affecting oxygen exchange across alveolar membrane
Pneumonia both affects ventilation and diffusion. An inflammatory reaction can occur in the alveoli, producing exudates that interfere in the diffusion of oxygen and carbon dioxide. White blood cells, mostly neutrophils, also migrate into the alveoli and fill the normally air-containing spaces. Areas of the lungs are not adequately ventilated because of secretions and mucosal edemathat cause partial occlusion of the bronchi or alveoli, with a resultant decrease in alveolar oxygen tension. An
Short term:After 4 hours of NI, the patient will demonstrate behaviors to improve or maintain airway patency.
Long term: After 4 days of NI, the patient will demonstrate absence or reduction of congestion with breath sounds clear, respirations noiseless and improved oxygen exchange.
>Establish rapport
>Assess patient’s condition
>Monitor VS
>Auscultate breath sounds
>Assess respiratory movements and use of accessory muscles
>Observe for signs and symptoms of infection
>Monitor chest radiograph reports
>to gain trust and cooperation
>to determine s/sx
>to obtain baseline data
>to note presence of adventitious breath sounds
>use of accessory muscles to breathe indicates and abnormal increase in work of breathing
>to identify infectious process and promote timely interventions
>to monitor the severity of the
Short term:After 4 hours of NI, the patient shall have demonstrated behaviors to improve or maintain airway patency.
Long term:After 4 days of NI, the patient shall have demonstrated absence or reduction of congestion with breath sounds clear, respirations noiseless and improved oxygen exchange..
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imbalance in oxygen and carbon dioxide exchange may be evident in the patient’s arterial blood gases. A decrease in oxygen supply may cause confusion and lethargy.
>Evaluate pulse oximeter to determine oxygenation
>Use positioning by placing on a semi-high fowler’s position
>Elevate head of bed or change position every 2 hours and prn
>Maintain adequate hydration when possible with precautions on fluid overload
>Perform nebulization and CPT as indicated
>Institute suctioning as needed
>Use naso-pharyngeal / oro- pharyngeal airway as needed
disease
>to assess respiratory insufficiency
>to facilitate lung expansion
> to take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage or ventilation to different lung segments
>to aid in the mobilization of secretions
>to loosen secretions
> to clear airway when secretions are blocking the airway
> to have patent airway through artificial means
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>Encourage adequate rest and limit activities to within client tolerance
>Administer medication as prescribed
>Administer analgesics as prescribed
>Refer to appropriate support groups
> helps limit oxygen needs/consumption
>to provide pharmacological management to treat condition
>to maximize cough when pain is inhibiting effort
> to promote continuity of care
Problem#4: Ineffective tissue perfusion (cardiac) r/t myocardial cell wall injury
Cues Nursing DiagnosisScientific
ExplanationObjectives
Nursing Interventions
Rationale Evaluation
S> The patient may verbalize:- sense of impending doom
O> The patient manifested:- dilated left ventricle with segmental wall motion abnormalities- severely depressed left ventricular systolic function with at least grade 3 left ventricular diastolic
Ineffective tissue perfusion (cardiac) r/t myocardial cell wall injury
Ineffective tissue perfusion is a decrease in Oxygen resulting in the failure to nourish the tissues and capillaries. Myocardial Infarction occurs when insufficient blood supply reaches the heart thus causing damage to the heart muscle. Possible contributing factors include dilation of
Short term:After 4 hours of NI, the patient will verbalize understanding of condition and therapy regimen and demonstrate lifestyle changes to improve circulation.
Long term: After 4 days of NI, the patient will
>Establish rapport
>Assess patient’s condition
>Monitor VS
>Review baseline ABGs, electrolytes, BUN/Cr, cardiac enzymes
> Assess for possible causative factors related to
>to gain trust and cooperation
>to determine s/sx
>to obtain baseline data
> to note degree of impairment/organ involvement
> Early detection of cause facilitates prompt, effective
Short term:After 4 hours of NI, the patient shall have demonstrated behaviors to improve or maintain airway patency.
Long term:After 4 days of NI, the patient shall have
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dysfunction- elevated CK–MB levels (47.4 ng/dl)- hgb levels below normal (124 g/dl)- hct levels below normal (0.39 g/dl)- chest pain- with oxygen hooked via nasal cannula regulated at 2 lpm- with condom catheter attached to urine bag- continuous cardiac monitoring
> The patient may manifest:- confusion- lethargy- abnormal ABG’s- cyanosis
the left ventricle which inhibits its normal pumping ability, thus reducing the blood supply that the heart and tissues demand. Also, in cases of low hemoglobin and hematocrit levels, the tissues would not receive the adequate amount of oxygen they need, and if left untreated would result to ischemia which may lead to an infarction. Certain cardiac markers may be used to diagnose an infarction such as CK-MB. Such would confirm an infarction if levels are seen elevated.
demonstrate increased perfusion as individually appropriate.
temporarily impaired arterial blood flow
> Maintain optimal cardiac output
> Encourage quiet, restful atmosphere
> Caution patient to avoid activities that increase cardiac workload. Encourage early ambulation, if possible
> Explain possible factors that may boost the occurrence of ineffective tissue perfusion
> Identify changes r/t systemic or peripheral alterations in circulation
>Administer medications with caution
treatment.
> This ensures adequate perfusion of vital organs. Support may be required to facilitate peripheral circulation (e.g., elevation of affected limb, antiembolism devices)
> to conserve energy and lowers tissue O2 demands
> to maximize tissue perfusion
> To impose awareness on the patient and SO
> To evaluate if further complications will occur
>Drugs that improve perfusion also carry the risk of adverse
demonstrated absence or reduction of congestion with breath sounds clear, respirations noiseless and improved oxygen exchange..
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>Discuss individual risk factors
>Instruct in blood pressure monitoring at home
response
>Information necessary for client to make informed choices about remedial risk factors and commitment to lifestyle changes, as appropriate, to prevent complications or manage symptoms when present
>Facilitates management of hypertension which is a major risk factor in the damage of blood vessels or organ dysfunction.
Problem#5: Decreased Cardiac Output
Cues Nursing DiagnosisScientific
ExplanationObjectives
Nursing Interventions
Rationale Evaluation
S> the patient may verbalize:- shortness of breath /dyspnea- fatigue- anxiety
O> The patient manifested:- dilated left ventricle with segmental wall motion abnormalities
Decreased cardiac output r/t altered stroke volume
The hypoxic tissue in myocardial infarction within the border zone may become a site for generating arrhythmias. Infracted tissue does not contribute to tension generation during systole, and therefore can alter ventricular systolic and diastolic function
Short term:After 4 hours of NI, the patient will participate in activities that decrease the workload of the heart such as stress managementor therapeutic medication regimen program
>Establish rapport
>Assess patient’s condition
>Monitor VS
>Monitor ECG for dysrrhythmias, conduction defects
> to gain trust and cooperation
> to determine signs and symptoms
> to obtain baseline data
> decrease in cardiac output may result in changes in
Short term:After 4 hours of NI, the patient shall have participated in activities that decrease the workload of the heart such as stress managementor therapeutic medication
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- severely depressed left ventricular systolic function with at least grade 3 left ventricular diastolic dysfunction- with oxygen hooked via nasal cannula regulated at 2 lpm- with condomcatheter attached to urine bag- continuous cardiac monitoring
The patient may manifest:- dysrhythmias- ECG changes- cyanosis- pallor- prolonged capillary refill- decreased peripheral pulses- variations in blood pressure readings
and disrupt electrical activity within the heart. Without improvement, the heart muscles may undergo remodeling such as hypertrophy, losing its normal pumping ability, thus may cause inadequate blood to meet the needs of the body’s tissues. Cardiac output and tissue perfusion are interrelated, thus a decrease in cardiac output may bring about cyanosis, pallor and prolonged capillary refill. There may also be fatigue and shortness of breath as there is not enough oxygen supplied to the tissues.
Long term: After 4 days of NI, the patient will display hemodynamic stability AEB normalization of ECG tracings and blood pressure readings
and for heart rate
>Monitor cardiac rhythms continuously
>Encourage patient to decrease intake of caffeine, cola and chocolates
>Observe skin color, temperature, capillary refill time and diaphoresis
>Monitor intake and output and calculate 24 hour fluid balance
>Administer supplemental oxygen as indicated
>Administer medicines as prescribed by the physician
>Promote adequate rest by decreasing stimuli providing
cardiac perfusion causing dysrhythmias
> to note for effectiveness of medicines
> caffeine is a cardiac stimulant and may adversely affect cardiac function
> peripheral vasoconstriction may result in pale, cool, clammy skin, with prolonged capillary refill time due to cardiac dysfunction and decreased cardiac output
> to maintain adequate nutrition and fluid balance
> to provide for adequate oxygenation
> to promote wellness
> to decrease oxygen consumption
regimen program
Long term:After 4 days of NI, the patient shall have displayed hemodynamic stability AEB normalization of ECG tracings and blood pressure readings
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quiet environment
>Encourage changing positions slowly, dangling legs before standing
>Instruct client & family on fluid and diet requirements and restrictions of sodium
> instruct client and family on medications, side effects, contraindications and signs to report
> to prevent occurrence of orthostatic hypotension
> restrictions can assist with decrease in fluid retention and hypertension, thereby improving cardiac output
> promotes knowledge and compliance with drug regimen
Problem#6: Risk for Aspiration
Cues Nursing DiagnosisScientific
ExplanationObjectives
Nursing Interventions
Rationale Evaluation
S> O
O> the patient manifested:- with productive cough- with presence of crackles on lower lobe of the right lung- with oxygen hooked via nasal cannula regulated at 2 lpm- with condom
Risk for Aspiration r/t presence of retained secretions
Pneumonai is a serious infection that affects the airsacs with accompanying secretions that may be expectorated.Sudden coughing may mobilize the secretions and may reach the airway which may cause distress to the patient’s breathing which is fatal.
Short term:After 4 hours of NI, the patient will be free from aspiration AEB having a patent airway
Long term: After 2 days of NI, the patient will
>Establish rapport
>Assess patient’s condition
>Monitor VS
> Monitor level of consciousness
>to gain trust and cooperation
>to determine signs and symptoms
>to obtain baseline data.
> A decreased level of consciousness is a prime risk factor for aspiration
Short term:After 4 hours of NI, the patient shall be free from aspiration AEB having a patent airway
Long term:After 2 days of NI,
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catheter attached to urine bag- continuous cardiac monitoring
>the patient may manifest:- respiratory distress
Usually when someone aspirates they cough in an attempt to clear the food or fluid out of their lungs.
experience no aspiration AEB noiseless respirations and clear breath sounds
> Keep suction setup available and use as needed
> Notify the physician or other health care provider immediately of noted decrease in cough and/or gag reflexes or difficulty in swallowing
>Assist with postural drainage
>Provide a rest period prior to feeding time
>Minimize use of sedatives/hypnotics whenever possible.
>Provide information on the effect of aspiration on the lungs
> This is necessary to maintain a patent airway
> Early intervention protects the patient’s airway and prevents aspiration
>to mobilize thickened secretions which may cause impairment in swallowing
>the rested client may have less difficulty in swallowing
>these agents can impair coughing or swallowing
>severe coughing and cyanosis associated with eating or drinking or changes in vocal quality after swallowing indicates onset of respiratory symptoms associated with aspiration and requires immediate interventions.
the patient shall have experienced no aspiration AEB noiseless respirations and clear breath sounds
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>Refer >to promote continuity of care
Problem#7: Anxiety
CuesNursing
DiagnosisScientific Explanation Objectives
Nursing Interventions
Rationale Evaluation
S= OO= pt. manifested
-with good skin turgor-with pale palpebral conjunctiva -with capillary refill 2 seconds- Cold clammy skin-with oxygen hooked via nasal cannula regulated at 2 lpm-with condom catheter attached to urine bag-continuous cardiac monitoring
Pt. may manifest:
-Sleep disturbance-Restlessness-Tachycardia-Tachypnea
Anxiety r/t perceived /actual threat of death, pain, possible lifestyle changes by restlessness
Coping with the pain and emotional trauma is difficult. Patient may fear death and or be anxious about immediate environment. Ongoing anxiety (related to concerns about impact of heart attack on future lifestyle, matters left unattended/unresolved and effects of illness on family) may be present in varying degrees for some time and maybe manifested by symptoms of depression such as sleep disturbance and restlessness.
Short term:
After 3-4 hours of nursing intervention pt will identify healthy ways to deal with and express anxiety.
Long term:
After 3 days of nursing intervention pt. will appear relaxed and report anxiety is reduced to a manageable level.
>Establish rapport
>Assess patient’s condition
>Monitor vital signs
>Observe for verbal/non-verbal signs of anxiety, and stay with the pt. Intervene if pt. displays destructive behavior.
>Maintain confident manner (without false reassurance)
>Orient pt/SO to routine procedures and expected activities
>Provide privacy for pt. and SO.
>To gain trust and cooperation
>To monitor physiologic condition
>To have baseline data
>to help pt. regain control of own behavior
>honest explanation can alleviate anxiety
>predictability and participation can decrease anxiety
>Allows needed time for personal expression of feelings, may enhance mutual
Short term:
After 3-4 hours of nursing intervention pt shall have identified healthy ways to deal with and express anxiety.
Long term:
After 3 days of nursing intervention pt. shall have appeared relaxed and reported anxiety is reduced to a manageable level.
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>Provide rest periods/uninterrupted sleep, quiet surroundings.
>Raise side rails
>Emphasize importance of adequate nutritional intake.
>Regulate and monitor IV fluid.
>Administer medications as ordered
support and promote more adaptive behaviors.
>Conserves energy and enhances coping abilities.
>to provide safety
> To maintain general good health.
>To promote fluid management.
>For optimum wellness
Problem#8: Fatigue
Cues Nursing DiagnosisScientific
ExplanationObjectives
Nursing Interventions
Rationale Evaluation
S > “agad ako napapagod, tulad pag maglalakad at maliligo ako”
O> The patient manifests: cold clammy skin dry skin weakness even with simple activities capillary refill < 3 sec.
Fatigue r/t decrease oxygenation and perfusion 2º pulmonary congestion
Fatigue is an overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level. Insulin is secreted by beta cells, which are one of four types of cells in the islets of Langerhans in the
Short term: After 3 hours of nursing interventions patient will be able to perform ADLs and participate in desired activities at level of ability.
Long term: After 1 day of nursing interventions
>Establish rapport
>Assess patient’s condition
> Monitor vital signs
> Instruct patient to increase fluid intake
>to gain the trust and cooperation of the patient.
>to have a general health status of the patient.
>to obtain baseline data
> a source of energy and
Short term: After 3 hours nursing interventions patient shall have performed ADLs and participate in desired activities at level of ability.
Long term: After 1 day of
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crackles on the right lung field v/s taken and recorded as follows:T=36ºC, RR=21 cpm, PR=65 bpm, BP=130/80 mmHg.
The patient may manifests: restlessness tachypnea
pancreas, insulin is a storage hormone, when a person eats a meal, insulin secretion increases and move glucose to the blood, into muscle, liver, and fat cells. Due to DM type 2 there is insulin resistance or impaired insulin secretion which results in the inhibition of the transport and metabolism of glucose into energy leading to easy fatigability AEB by pt. weakness even doing activities of daily living.
patient will report improve sense of energy.
up to 8- 10 glasses of water
> Instruct to sit instead of standing during activities or shower
>Instruct patient to increase intake of vitamin or iron supplementation like juice
>Stretch linens
>Assist with self-care needs like keep bed in low position
>Stress proper hand washing
>Administer drugs as ordered.
to prevent dehydration
> to conserve energy
> to promote overall health measures.
>to provide comfort
>To conserve energy
>to prevent infection.
> for optimum wellness
nursing interventions patient shall have reported improve sense of energy.
Problem#9: Risk for Infection
Cues Nursing DiagnosisScientific
ExplanationObjectives Nursing Interventions Rationale Evaluation
S> O
O> The patient manifested:- productive cough- with oxygen hooked via nasal cannula regulated at 2 lpm- with condom
Risk for Infection r/t inadequate primary defenses (decreased ciliary action)
Upper airway characteristics normally prevent potentially infectious particles from reaching the sterile lower respiratory tract. Pneumonia involves the inflammation of the
Short term:After 2 hours of nursing intervention patient will identify interventions to prevent/reduce risk/spread of/secondary infection.
>Establish rapport
>Assess patient’s condition
>Monitor VS
>Obtain appropriate
>to gain trust and cooperation
>to determine s/sx
>to obtain baseline data
>for observation for
Short term:After 2 hours of NI, the patient shall have identified interventions to prevent/reduce risk/spread of/secondary infection..
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catheter attached to urine bag- continuous cardiac monitoring
> The patient may manifest:- fever- chills- DOB- increase in RR, PR- increase in WBC levels and neutrophils
lung parenchyma which eventually leads to a decreased ciliary action and may further lead to stasis of respiratory secretions the client is at risk for the spread of infection since the continuous production of mucus secretions is a perfect breeding place for microorganisms. And if the body does not cope well the infection may spread to the rest of the body.
Long term: After 4 days of NI, the patient will achieve timely resolution of current infection without complications.
tissue/fluid specimens
>Stress proper hand washing techniques by all care givers between therapies and client
>Encourage coughing &, position change
>Monitor client’s visitors or caregivers for presence of respiratory illnesses. Offer masks/tissues to client/visitors who are coughing or sneezing
>Encourage deep breathing, coughing and frequent position changes
> Encourage adequate rest balanced with moderate activity. Promote adequate nutritional intake
>Administer or monitor medication regimen and note client’s response
culture and sensitivity testing
> it is a first line defense against nosocomial infection or cross contamination
>for mobilization of respiratory secretions
>to limit exposures, thus reduce cross contamination
>for mobilization of secretions and prevention of aspiration or respiratory infection
> Facilitates healing process and enhances natural resistance.
>to determine effectiveness of therapy and presence of side effects
Long term:After 4 days of NI, the patient shall have achieved timely resolution of current infection without complications
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>Administer prophylactic antibiotic as indicated
> Investigate sudden changes/deterioration in condition, such as increasing chest pain, extra heart sounds, altered sensorium, recurring fever, changes in sputum characteristics
>Review individual nutritional needs, appropriate exercise program and need for rest
>Emphasize needs for taking antiviral or antibiotics as directed
>Provide information or involve in appropriate community and national education programs
>to correct nor reduce existing risk factors
> Delayed recovery or increase in severity of symptoms suggests resistance to antibiotics or secondary infection
>to promote wellness
>Premature discontinuation of treatment when client feels well may result in return of infection and may potentiate drug-resistant strains
>to increase awareness of and prevention of aommunicable diseases
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Problem#10: Activity Intolerance
Cues Nursing DiagnosisScientific
ExplanationObjectives
Nursing Interventions
Rationale Evaluation
S> The pt. may verbalize:- exertional dyspnea or discomfort- reports of fatigue or weakness
O> the patient manifested:- need for assistance upon movement- limited range of motion- with oxygen hooked via nasal cannula regulated at 2 lpm- with condomcatheter attached to urine bag- continuous cardiac monitoring
The patient may manifest:- tachypnea and increased blood pressure upon performance of activities- pallor- cyanosis- ischemic ECG changes
Activity Intolerance r/t cardiac dysfunction, imbalance in oxygen supply and consumption as evidenced by shortness of breath upon exertion
The underlying mechanism of a heart attack is the destruction of heart muscle cells due to a lack of oxygen. If these cells are not supplied with sufficient oxygen by the coronary arteries to meet their metabolic demands, they die by a process called infarction. The decrease in blood supply may bring about necrosis of the heart muscle which would make it weaker as a pump. As a result, the pumping mechanism of the heart will be ineffective thus giving the individual an insufficient supply of blood, bringing about an inefficient supply of oxygen to the tissues thus leading to easy fatigability upon simple exertions. If the condition becomes severe, the
Short term:After 4 hours of NI, the patient will use identified techniques to increase activity tolerance.
Long term: After 4 days of NI, the patient will be able to increase and achieve desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise.
>Establish rapport
>Assess patient’s condition
>Monitor VS
>Identify causative factors leading to intolerance of activity
>Encourage patient to assist with planning activities, with rest periods as necessary
>Instruct patient in energy conservation techniques
>Assist with active or passive ROM exercises
>to gain trust and cooperation
>to determine signs and symptoms
>changes in VS assist with monitoring physiologic responses to increase in activity.
>alleviation of factors that are known to create intolerance can assist with development of an activity level program
> to help give the patient a feeling of self-worth and well-being
> to decrease energy expenditure and fatigue
> to maintain joint mobility and muscle tone
Short term:After 4 hours of NI, the patient shall have used identified techniques to increase activity tolerance.
Long term:After 4 days of NI, the patient shall have increased and achieved desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise
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patient may have inability in performing activities and show changes in vital signs upon performance of activities. Also, there could be changes in the ECG showing signs of ischemia.
>Assist patient with ambulation, as ordered, with progressive increases as patient’s tolerance permits
>Adjust activities according to patient’s tolerance
>Plan care with rest periods between activities
>Provide positive atmosphere, while acknowledging difficulty of the situation for the patient
>Assist patient with activities and monitor use of assistive devices
>Promote comfort measures and provide for relief of pain
>Provide referral to other disciplines as indicated
> Instruct client/SO in monitoring response to activity
> to gradually increase the body to compensate for the increase in overload
> to prevent overexertion
> to reduce fatigue
> helps to minimize frustration, rechannel activities
> to protect client from injury
> to enhance ability to participate in activities
> to develop individually appropriate treatment regimen
> may indicate a need in alteration of activities
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and recognizing signs and symptoms
Problem#11: Self Care Deficit r/t weakness
Cues Nursing DiagnosisScientific
ExplanationObjectives
Nursing Interventions
Rationale Evaluation
S > ØO> The patient manifests:
cold clammy skin good skin turgor capillary refill < 3 sec. irritability weakness when taking a bath easy fatigability even only doing ADLs
The patient may manifests:
restlessness
Self care deficit related to weakness or tiredness.
The nurse may encounter the patient with self - care deficit in the hospital. The deficit may be a result of transient limitations, such as those one might experience while recovering from surgery or the result of the progressive deterioration that erodes the individual’s ability or willingness to perform the activities required to care for himself. Careful examination of the patient’s deficit is required in order to be certain that the patient is not failing self-care because of lack of materials with arranging the environment to suit the patient’s physical limitations.
Short term: After 3 hours of nursing interventions patient will be able to verbalize understanding on the importance of self-care.
Long term: After 1 day of nursing interventions patient will safely perform self-care activities.
>Establish rapport
>Assess patient’s condition
> Monitor vital signs
>Assist with necessary adaptations to accomplish ADLs
> Arrange for assistive devices as necessary (seat/grab bars)
>Instruct patient to increase fluid intake up to 8- 10 glasses of water
>Encourage food choices reflecting individual likes and abilities that meet nutritional needs
>to gain the trust and cooperation of the patient.
>to have a general health status of the patient.
>to obtain baseline data
> to encourage and build on successes
> to prevent injury
> to prevent dehydration and a source of energy
> to increase energy
Short term: After 3 hours nursing interventions patient shall have verbalized the importance of self-care.
Long term: After 1 day of nursing interventions patient shall have performed safely self-care activities.
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>Stretch linens
>Stress proper hand washing
>Instructed patient to perform good hygiene
>Administer drugs as ordered.
>to provide comfort
>to prevent infection.
>To relieve patient and provide comfort
> for optimum wellness
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