Care Plan Exercise

8/10/2019 Care Plan Exercise

1/19

Care Plan Exercise

Cristi Day RN, MSN, FNP-C

Texas A&M University

Corpus Christi


2/19

Ineffective Tissue Perfusion: Cardiopulmonary

Definition: Decrease in oxygen resultingin failure to nourish tissues at capillarylevel

Defining Characteristics (AEB): use ofaccessory muscles, capillary refill longerthan 3 seconds, abnormal ABGs, chestpain, sense of impending doom,bronchospasm, dyspnea, dysrhythmias,nasal flaring, chest retraction.


3/19

Ineffective Tissue Perfusion: Cardiopulmonary

Contd

Related Factors (R/T): Hypovolemia,

interruption of arterial flow, hypervolemia,

exchange problems, interruption of venous

flow, mechanical reduction of venous and/orarterial blood flow, hypoventilation, impaired

transport of oxygen across alveolar and/or

capillary membrane, mismatch of ventilation

with blood flow, decreased hemoglobinconcentration in blood, enzyme poisoning,

altered affinity of hemoglobin of oxygen


4/19

Ineffective Tissue Perfusion Nursing Diagnosis

Statement

Ineffective Tissue Perfusion:

cardiopulmonary R/T interruption of

aterial flow AEB altered RR, CP,sense of impending doom, dyspnea


5/19

Ineffective Tissue Perfusion: Care Map

Ineffective Tissue Perfusion:cardiopulmonary R/Tinterruption of aterial flow

AEB altered RR, CP,sense of impendingdoom, dyspnea

RR

24

CP

8/10Fees like

he going to

die

SOB


6/19

Ineffective Tissue Perfusion: Outcome Goals

1. Client will demonstrate adequate

tissue perfusion as evidenced by:skin warm & dry, absence ofdyspnea, absence of chest pain,absence of feelings of impendingdoom within 2 hours of admission.

2. Client will verbalize knowledge of

treatment regimen includinglifestyle modifications, medicalnutrition therapy, and medicationregimen actions and possible sideeffects before discharge fromacute care.


7/19


Ineffective Tissue Perfusion:cardiopulmonary R/Tinterruption of aterial flow

AEB altered RR, CP,sense of impendingdoom, dyspnea

RR

24

CP

8/10Fees like

he going to

die

SOB

1. Client will demonstrateadequate tissueperfusion as evidencedby: skin warm & dry,absence of dyspnea,absence of chest pain,& absence of feelings

of impending doomwithin 2 hours ofadmission.

2. Client will verbalizeknowledge oftreatment regimenincluding lifestylemodifications, medicalnutrition therapy, andmedication regimen

actions and possibleside effects beforedischarge from acute


8/19

Ineffective Tissue Perfusion: Interventions

Teach client/family importance and methods of

lifestyle modification and dietary modifications for

smoking cessation, hyperlipidemia control, HTN

control. RA: All these risk factors for

atherosclerosis can be modified. (A&L p 1237)

Teach client/family about medications, their

regimen, actions, and side effects. RA:

Appropriate instruction increases accuracy &

safety of medication administration. (A&L p 904)

Assess for signs of decreased tissue perfusion:

CP, clammy skin, dyspnea, feelings of impending

doom. RA: Indicative of inadequate blood supply

to myocardium (A&L p269)

Administer nitroglycerin SL and oxygen asordered. RA: This improves myocardial perfusion(http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Const

ructor/index.cfm?plan=55

Anticipate need for possible embolectomy, heparinization, vasodilator

therapy, thrombolytic therapy, and fluid rescue. RA: These facilitate

perfusion when obstruction to blood flow exists or when perfusion hasdropped to such a danger level that ischemic damage would be

inevitable without treatment.

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=5

5


9/19


Ineffective Tissue Perfusion:cardiopulmonary R/Tinterruption of aterial flow AEBaltered RR, CP, sense ofimpending doom, dyspnea

RR

24

CP

8/10Fees like

hes going

to die

SOB

Client will demonstrateadequate tissueperfusion asevidenced by: skinwarm & dry,absence ofdyspnea, absenceof chest pain, &absence of feelingsof impending doomwithin 2 hours of

admission.Client will verbalize knowledge

of treatmentregimen includinglifestylemodifications,medical nutritiontherapy, andmedication regimenactions andpossible sideeffects before

discharge fromacute care.

Assess for signs of decreased tissue perfusion: CP,

clammy skin, dyspnea, feelings of impending doom.

RA: Indicative of inadequate blood supply to

myocardium (A&L p269)

Teach client/family about medications, their regimen,

actions, and side effects. RA: Appropriate

instruction increases accuracy & safety of medicationadministration. (A&L p 904)

Teach client/family importance and methods of

lifestyle modification and dietary modifications for

smoking cessation, hyperlipidemia control, HTN

control. RA: All these risk factors for atheroslerosis

can be modified. (A&L p 1237)

Administer nitroglycerin SL and oxygen as ordered.

RA: This improves myocardial perfusion

(http://www1.us.elsevierhealth.com)

Anticipate need for possible embolectomy,

heparinization, vasodilator therapy, thrombolytic

therapy, and fluid rescue. RA: These facilitate

perfusion when obstruction to blood flow exists

or when perfusion has dropped to such a

danger level that ischemic damage would be

inevitable without treatment.

http://www1.us.elsevierhealth.com


10/19

Ineffective Tissue Perfusion: Evaluation

1. Client will demonstrateadequate tissue perfusionas evidenced by: skinwarm & dry, absence ofdyspnea, absence of chestpain, & absence of feelingsof impending doom within2 hours of admission.

2. Client will verbalizeknowledge of treatmentregimen including lifestylemodifications, medical

nutrition therapy, andmedication regimenactions and possible sideeffects before dischargefrom acute care.

1. Goal Partially Met.Client skin

warm and dry, no c/o dyspnea, chest

pain resolved, and feelings of

impending doom resolved within 8

hours of admission.

2. Goal Met. Client verbalizes

understanding of activity and dietary

changes needed to modify risks for CADand verbalizes understanding of

medications, their actions and side effects

prior to discharge to home.


11/19

Activity Intolerance

Definition: Insufficient physiological or

psychological energy to endure or complete

required or desired daily activities.

Defining Characteristics (AEB): Verbal reportof fatigue or weakness, abnormal heart rate or

blood pressure response to activity, exertional

discomfort or dyspnea, electrocardiographic

changes reflecting arrhythmias or ischemia.


12/19

Activity Intolerance - Contd

Related Factors (R/T): Bed rest or

immobility, generalized weakness,

sedentary lifestyle, imbalance between

oxygen supply and demand.


13/19

Activity Intolerance

Nursing Diagnosis Statement

Activity Intolerance R/T imbalance

between oxygen supply and

demand (CHF decreased CardiacOutput) AEB fatigue, exertional

dyspnea.


14/19

Activity Intolerance : Care Map

Activity Intolerance R/Timbalance betweenoxygen supply anddemand (CHF decreasedCardiac Output) AEBfatigue, exertionaldyspnea.

c/o

fatigue

Exertional

dyspnea


15/19

Activity Intolerance : Outcome Goals

1. Client will demonstrate increased

activity intolerance (decreasereport of fatigue and decreasedexertional dyspnea by time ofdischarge.

2. Client will verbalize anunderstanding of the need to

gradually increase activity basedon testing, tolerance, andsymptoms by end of second dayof admission.


16/19

Activity Intolerance : Interventions

Consider us of the 6-minute walk test to determine

physical ability. RA: The 6-minute walk test was

shown to be highly reproducible in determining

ability to ambulate in a client in Heart Failure.

(A&L p 152)

Allow for periods of rest before and after plannedexertion periods. RA: Limited exercise toleratnce

in heart failure is often the first and central clinical

feature, reflecting both decreased cardiac and

peripheral responses. (A&L 152)

Help client to set up an activity log to record

exercise and exercise tolerance. RA: Will help

client to understand his level of activity tolerance.(A&L 155)

Provide emotional support and encouragement

to the client to gradually increase activity. RA:

Fear of breathlessness, pain, or falling may

decrase willingness to increase activity. (A&L

151)

Refer to cardiac rehab program for education,

evaluation, and support to increase activity and

rebuild life. RA: Exercise can help many client

with heart failure. A carefully monitored

exercise program can improve both exercise

capacity and quality of life in mild to moderate

heart failure clients (A&L 152)


17/19

Activity Intolerance : Care Map

Activity Intolerance R/T

imbalance betweenoxygen supply anddemand (CHF decreasedCardiac Output) AEBfatigue, exertionaldyspnea.

c/o

fatigue

Exertional

dyspnea

1. Client will

demonstrate

increased activity

intolerance(decrease report of

fatigue and decreased

exertional dyspnea by

time of discharge.

2. Client will verbalize

an understanding of

the need to

gradually increase

activitybased on

testing, tolerance, andsymptoms by end of

second day of

admission.

Consider us of the 6-minute

walk test to determine

physical ability. RA: The 6-minutewalk test was shown to be highly reproducible in

determining ability to ambulate in a client in Heart

Failure. (A&L p 152)

Allow for periods of restbefore and after planned

exertion periods.RA: Limitedexercise tolerance in heart failure is

often the first and central clinical

feature, reflecting both decreased

cardiac and peripheral responses.

(A&L 152)

Help client to set up an activity

log to record exercise and

exercise tolerance. RA: Willhelp client to understand his level

of activity tolerance. (A&L 155)

Provide emotional support

and encouragement to the

client to gradually increase

activity. RA: Fear of breathlessness, pain,or falling may decrase willingness to increase

activity. (A&L 151)

Refer to cardiac rehabprogram for education,

evaluation, and support to

increase activity and

rebuild life. RA: Exercise canhelp many client with heart failure. A

carefully monitored exercise program

can improve both exercise capacity

and quality of life in mild to moderate

heart failure clients (A&L 152)


18/19

Activity Intolerance : Evaluation

1. Goal met. Client demonstrated

increased activity intolerance. Able to

walk 150 ft without significant dyspnea

and without report of fatigue by

discharge home (4 days).

2. Goal met. Client was able to

identify activity tolerance and

symptoms of intolerance and

verbalized understanding of theneed to gradually increase his

activity by the 2ndday of

admission.

1. Client will demonstrate

increased activity

intolerance (decrease

report of fatigue anddecreased exertional

dyspnea by time of

discharge.

2. Client will verbalize an

understanding of the

need to gradually

increase activity basedon testing, tolerance, and

symptoms by end of

second day of admission.


19/19

CARE PLAN EVALUATION FORM

Problem List:

High Risk Actual

Problems identified come from assessment data

All problems are noted that assessment data shows/ Priorities identified. 10

Nursing Diagnostic Statement:

Stated in nursing terms (NANDA format)

Related to is pathophysiologically based

Supported by Objective Data

Supported by Subjective Data 10

Goals and Outcomes:

Relate to Problem Long and Short Term Goal,

States desired patient outcome criteria

Realistic time frame Measurable 10

Carative Factors/Interventions:

Contain what, how much, where, when

Related to goals and outcomes

Could be completed by another nurse for the client 10

Rationale:

Based on Valid Theory; States what the nursing action modifies

within the body to accomplish the desired outcome

Refers to interventions, References (page and source) 10

Evaluation:

States how goal was met or not met

Recommended changes

Based on outcome criteria 10

Care Plan Exercise

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