nC

name of paLlenL Wu CC nape and chesL paln

Age 68 yo

Cues

ulagnosls

8aLlonale

Coal

lnLervenLlon

8aLlonale

evaluaLlon
Sub[ecLlve
1he cllenL reporLs
o dlna hapo ako
kun dlna kapoy"

Cb[ecLlve
Olncreased
blood
pressure
8p
140/80
Ouyspnea wlLh
exerLlon
OaLlgue and
weaknes

Weakness Age
(67yo)

SLrenghLs Able Lo
comply wlLh
medlcaLlons
AcLlvlLy lnLolerance
r/L cardlac
dysfuncLlon
changes ln oxygen
supply and
consumpLlon as
evldenced by
shorLness of breaLh

ueflnlLlon
lnsufflclenL
physlologlcal or
psychologlcal
energy Lo endure or
compleLe requlred
or deslred dally
acLlvlLles

Source nAnuA
Weakness and faLlgue



uecreased oxygen



lncreased CC
2
levels



uecreased 8ld pP



ueep and labored
breaLhlng
S1C
WlLhln 3 days of
nurslng lnLervenLlons
Lhe cllenL wlll be able Lo
LoleraLe acLlvlLy wlLhouL
excesslve dyspnea and
wlll be able Lo uLlllze
breaLhlng Lechnlques
and energy conservaLlon
Lechnlques effecLlvely

L1C
WlLhln 3 days of
nurslng lnLervenLlons
Lhe cllenL wlll be able Lo
lncrease and achleve
deslred acLlvlLy level
progresslvely wlLh no
lnLolerance sympLoms
noLed such as
resplraLory compromlse
lnuLLnuLn1
1 monlLor hearL raLe
rhyLhm resplraLlons and
blood pressure for
abnormallLles noLlfy
physlclan of slgnlflcanL
changes ln vS

2 ldenLlfy causaLlve facLors
leadlng Lo lnLolerance of
acLlvlLy

3 encourage paLlenL Lo asslsL
wlLh plannlng acLlvlLles wlLh
resL perlods as necessary

4 lnsLrucL paLlenL ln energy
conservaLlon Lechnlques

3 Lurn paLlenL aL leasL every
2 hours and prn

7 lnsLrucL paLlenL ln
lsomeLrlc and breaLhlng
exerclses



1changes ln vS asslsL wlLh monlLorlng
physlologlc responses Lo lncrease ln
acLlvlLy

2 AllevlaLlon of facLors LhaL are
known Lo creaLe lnLolerance can asslsL
wlLh developmenL of an acLlvlLy level
program

3 Lo help glve Lhe paLlenL a feellng of
selfworLh and wellbelng

4 Lo decrease energy expendlLure and
faLlgue

3 Lo malnLaln [olnL moblllLy and
muscle Lone

7 Lo lmprove breaLhlng and Lo
lncrease acLlvlLy level





S1C
WlLhln 3 days of
nurslng lnLervenLlons
Lhe cllenL LoleraLed
acLlvlLy wlLhouL
excesslve dyspnea and
had been able Lo uLlllze
breaLhlng Lechnlques
and energy conservaLlon
Lechnlques effecLlvely
Coal was meL

L1C
WlLhln 3 days of
nurslng lnLervenLlons
Lhe cllenL lncreased and
achleved deslred acLlvlLy
level progresslvely wlLh
no lnLolerance
sympLoms noLed such
as resplraLory
compromlse
Coal was meL
nC
name of paLlenL Wu CC knap and chesL paln
Age 68 yo

Cues

ulagnosls

8aLlonale

Coal

lnLervenLlon

8aLlonale

evaluaLlon
Sub[ecLlve


Cb[ecLlve
8140/90

leLhargy

pallor

resLless

cold clammy skln

Weakness Age
(67yo)

SLrenghLs Able Lo
comply wlLh
medlcaLlons
lneffecLlve cardlac
Llssue perfuslon r/L
lnLerrupLlon of
blood flow 2/L a
known case of
myocardlal
lnfarcLlon

ueflnlLlon
uecrease resulLlng
ln Lhe fallure Lo
nourlsh Lhe Llssues
aL Lhe caplllary level

Source nAnuA
Myocardlal lnfarcLlon


Myocardlal Llssue ls
desLroyed


CrlLlcal narrowlng of
coronary arLery


reduced coronary
arLery blood flow

deprlved of an
adequaLe supply of
blood

resulL Lo vasospasm of
coronary arLery


decreased oxygen
supply

lneffecLlve cardlac
Llssue perfuslon
AfLer 8 hrs of nurslng
lnLervenLlon Lhe pL wlll
be able Lo
reduced Lhe 8 from
140/90
1o 120/80

verballze comforL
lnuLLnuLn1
1 lnvesLlgaLe sudden
changes or conLlnued
alLeraLlon ln
menLaLlon

2 lnspecL for pallor
cyanosls moLLllng
cool/clammy skln
noLe sLrengLh of
perlpheral pulse


3 MonlLor resplraLlons
noLe work of
breaLhlng


4 monlLor lnLake noLe
changes ln urlne
ouLpuL 8ecord urlne
speclflc gravlLy as
lndlcaLed




1 Cerebral perfuslon ls dlrecLly relaLed
Lo cardlac ouLpuL and ls also
lnfluenced by elecLrolyLe/ acldbase
varlaLlons hypoxla and sysLemlc
emboll


2 SysLemlc vasoconsLrlcLlon resulLlng
from dlmlnlshed cardlac ouLpuL may
be evldenced by decreased skln
perfuslon and dlmlnlshed pulse

3 Cardlac pump fallure and or
lschemlc paln may preclplLaLe
resplraLory dlsLress however
sudden/conLlnued dyspnea may
lndlcaLe Lhromboembollc pulmonary
compllcaLlons

4 uecreased lnLake/perslsLenL nausea
may resulL ln reduced
clrculaLlngvolume w/c negaLlvely
affecLs perfuslon and organ funcLlon
Speclflc gravlLy measuremenLs reflecL
hydraLlon sLaLus and renal funcLlon



AfLer 8 hrs on nurslng
lnLervenLlon

bp was reduced
from 140/90 Lo
110/70 Coal
meL

paLlenL was able
Lo verballze
comforL Coal
meL