NURSING CARE PLAN Cues  Subjective: “Ayaw niya masyasong magkikilos dahil mabilis siyang mapagod; nanghihina at nahihilo

siya” as verbalized by the patient’s wife.  Objective  Cold and clammy skin on both feet.  Increased capillary refill time (4-5 secs)  Fatigue  Body weakness  Vital Signs:  Temp:37.5oC  RR: 30 cpm  PR: 94 bpm  BP: 140/100 Nursing Diagnosis Decreased cardiac output related to reduced myocardial perfusion. Inference Goals After 24 hours of nursing intervention the patient will: 1. Not experience tachypnea, restlessness, anxiety, dyspnea, confusion, fainting, dizzy spells, lightheadedness, nausea, fatigue, or weakness. 2. Tolerate exercise and activities at usual level, taking into account any cardiac damage. 3. Maintain respiratory status within established parameters. 4. Patient’s cardiac status will stabilize, with no evidence of arrhythmias. 5. Assess apical Nursing Interventions 1. Administer medication as ordered and monitor intake and output, and observe adverse reaction. 2. Monitor for dyspnea or breathlessness every 2 to 4 hours, and report changes from baseline. 3. Monitor mental status every 2 to 4 hours and report deviations from baseline. Rationale 1. Decreased renal and liver function may lead to rapid development of toxicity. Evaluation Goal Met: After 24 hours of nursing intervention the patient had: 1. experienced fewer dyspneic episodes, with no syncope or dizzy spells. 2. Returned to normal activity and exercise levels, taking into account extent of cardiac damage. 3. Maintained normal respiratory status. 4. Physical examination reveals that arrhytmias are absent. 5. Patient and family members understand and comply with prescribed

Fatigue

Decreased blood flow to the myocardium

Decreased O2 supply

Ischemia Anaerobic metabolism

2. Patients with silent myocardial infarction frequently develop dyspnea related to left-sided heart failure. 3. Dizziness, confusion, lightheadedness, and restlessness may indicate cerebral blood flow caused by slow carotid sinus reflex. 4. When fluid in the lungs and lower extremities is mobilized and returns to circulation, it may ovetax the patient’s weakened myocardium.

Inability to function as a pump

Decreased left ventricle function

4. Administer diuretics cautiously to the patient.

Decreased cardiac output

5. Patient and family members will understand and comply with prescribed therapeutic regimen.

and radial pulses every 2 to 4 hours and report deviation from baseline. 6. Administer oxygen to the patient as prescribed by the physician. 7. Make sure that the patient gets adequate rest and doesn’t exceed his activity tolerance level.

5. To monitor for arrhythmias, impending cardiac arrest, hypertension, or shock. 6. To increase oxygenation of the brain and heart.

therapeutic regimen.

7. To ease dyspnea, decrease oxygen demand on myocardium, and prevent hydrostatic pneumonia, venous thrombosis, and cardiovascular deconditioning. 8. To avoid Valsalva’s manuever during defecation, which can increase heart rate and blood pressure, cause bradycardia reflex, and decrease cardiac output.

8. Encourage patient to increase fluid intake and dietary fiber and to take natural stool softeners.

Cues  Subjective: “Ayaw niya masyasong magkikilos dahil mabilis siyang mapagod; nanghihina at nahihilo siya” as verbalized by the patient’s wife.  Objective  Cold and clammy skin on both feet.  Increased capillary refill time (4-5 secs)  Fatigue  Body weakness  Vital Signs:  Temp:37.5oC  RR: 30 cpm  PR: 94 bpm  BP: 140/100

Nursing Diagnosis Activity Intolerance related to compromised oxygen transport secondary to congestive heart failure.

Inference

Goals After 24 hours of nursing intervention the patient will: 1. State desire to increase activity level. 2. State understanding of the need to increase activity level gradually.

Nursing Interventions 1. Assess capillary refill in both upper and lower extremities. 2. Monitor vital signs and obtain baseline O2 saturation.

Rationale 1. To assess presence of blood flow in the client’s upper and lower extremities. 2. To obtain baseline vital signs for future comparison as well as to assess any improvement in the level of oxygen in the extremities. 3. Identify how much stress the heart and lungs can tolerate during usual activities. 4. To allow lung expansion 5. Cold temperature constricts blood vessels.

Evaluation Goal Met: After 24 hours of nursing intervention the patient had: 1. Stated a desire to increase activity. 2. Identified a plan to increase activity level. 3. Listed factors that cause fatigue. 4. Patient’s blood pressure, pulse, respiratory rates remain within normal parameters. 5. Expressed satisfaction with increase in activity level.

Imbalance between oxygen supply and demand

Cardiac cells utilize anaerobic metabolism

Decreased cerebral perfusion

Dizziness

Increased ATP and lactic acid

Acidosis

Cellular Disturbance

Deep Inspiration

Myocardial cell sense pH change and become less fuctional

Left ventricular dysfunction Reduced Contractility

3. Identify 3. Assess controllable factors cardiopulmonary that cause fatigue. response during client activities 4. Patient’s blood before, during, pressure and pulse after. and respiratory rates will remain 4. Encourage within prescribed coughing exercise limits during activity. 5. Advise client to avoid cold places 5. Demonstrate skill in conserving energy while carrying out daily 6. Monitor blood activities to glucose regularly. tolerance level. 6. Explain illness and connect symptoms of activity intolerance with deficit in oxygen supply or use.

7. Advise client bed rest. 8. Administer oxygen as

6. Patient is proficient in 6. Increase in blood conserving energy. glucose causes the blood to be viscous 7. Demonstrated resulting to an understanding decreased blood relationship flow. between signs and 7. To decrease symptoms of oxygen activity intolerance consumption. and deficit in oxygen supply or 8. To provide use. additional oxygen to

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