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urine, headaches, headaches, I do not see well, and even after doing something small, I become very tired easily and for the first time I have experienced nose bleeding. So I do not understand what is happening to me these days´´ verbalised Mr Neck.
Objective data: • • • • Decreased cardiac output Decreased stroke volume Increased peripheral vascular resistance Vitals taken as follows:
-Temperature: 37.2 °C -Pulse rate: 83beats/minutes -Respiration rate: 18breaths/minutes -Blood pressure: 180/100mmHg
Nursing diagnosis: Knowledge deficit related to the underlying heart disease, its consequences and treatment regimen evidenced by verbalisation of patient. Goal -Patient will demonstrate understanding of underlying disease process and identify own risk factors or precipitating conditions that require modification within 2 days of nursing interventions. Nursing intervention -Assess knowledge of hypertension, underlying disease process, and expectations of disease progression. Rationale -Assessment establishes baseline data from which to build or determine need to alter misconceptions. Evaluation
-After 2 days of the nursing intervention, the patient was able to demonstrate an understanding of the underlying disease process and was able to -Encourage -It promotes the patient identify own risk verbalisation of patient and family engagement factors or precipitating and family concerns in the nursing care. conditions that require and their learning modification. needs. -Assess readiness to learn. -Implement teaching plan, which should include: • Explanation of -Readiness facilitates more effective learning. -Patient and family have a right to receive information about the disease, treatment, and
related to potential for lifestyle modification. Goal Patient will verbalize feelings of less anxiousness and fears within 24 hours of nursing intervention. . heart failure.• • • normal heart. frequency. -Make the patient a handout to read in simple language about the disease which may incorporate weight control. Explanation of signs and symptoms and risk factors and factors which will aggravate the symptoms of heart failure and methods to modify them. family members. -Assist patient/family in identifying family strengths and resources. knowledge allays anxieties and the adverse effects associated with psychological stress. -This will help equip the patient with more knowledge and enable them make appropriate decisions about life style changes and compliance to medication. Explanation of medication regimen (names. Nursing diagnosis Anxiety. Nursing intervention -Obtain baseline assessment of anxiety level and coping patterns from patient. Explanation of diet modification if indicated. and underlying disease process. dietary habits and medication . dosage.This helps to enhance self confidence. intensive care setting and diagnosis made evidenced by patient verbalising feelings of fears. the patient was able to verbalize feelings of less anxiousness and fears. action and possible side effects. or Rationale -Baseline data are essential in evaluating the effectiveness of therapeutic interventions and the Evaluation After 24 hours. prognosis: understanding enhances compliance.
significant others. increased muscle tension. provide positive reinforcement when appropriate. Nursing diagnosis Non-compliance with the plan of therapy related to knowledge deficit. encourage them to ask questions. -Assess level of anxiety. • Encourage the patient/family -Knowing what to to verbalize expect will help reduce anxieties and anxiety. change in sleeping patterns. failure to follow a prescribed regimen. -Assists in determining the underlying cause of anxiety and provides a basis f or intervention. -Determine what the individual´s needs are and what resources can be mobilized to decrease feelings of anxiety. • Explain procedures and -Will decrease anxiety by re-establishing sense limitations to of control and purpose. patient and family.Assess patients -Inaccurate perception -After the first one . inadequate support system. • Familiarize patient with ICU staff. or lack of involvement in the treatment plan evidenced by the patient verbalizing about forgetting medication time. Goal Nursing intervention Rationale Evaluation Patient demonstrate a . concerns. routines. is not alone. irritability. patients ability to cope. -Positive feedback helps nurture confidence. measures to decrease reassures patient that he anxiety. • Involve patients in their own care within physical limitations. -Helps to create a -Implement therapeutic trusting relationship. blood pressure. include heart rate. and equipments.
-Explain the regimen to -Enhances compliance the patient. week of nursing care. weight. diet. smoking and alcohol. -Assess patient´s self care performance a) Determine baseline compliance regarding medications. its benefits and satisfaction. held by the patient about the disease and its treatment must be identified and corrected because misconceptions about the disease can easily affect compliance. -Provide continual feedback and reinforcement of adherence behaviour. and some of the problems he will encounter. -This enhances compliances and satisfaction. Encourage the patient to express fears or frustrations he has related to his health needs -Encourage active participation by the patient and the family for example monitor their blood pressure from home if he has the blood pressure machine. Nursing diagnosis Decreased Cardiac Output related to malignant hypertension as evidenced by decreased stroke . the patient had an understanding. -Patient is likely to take an active role in his care if he believes that he has control over treatment outcomes. and and treatment.understanding. stress management. Fears and frustrations about prescribed treatment can interfere with compliance. and implementation of the prescribed treatment regimen. exercise. implementation of the prescribed treatment regimen within the first week of nursing care. acceptance. perception of his illness acceptance. b) Monitor and record improvement in compliance.
8. Monitor BP every 1-2 hours. Goal was met. blood pressure maintained within set parameters for the client. Goal Short term goal After 6 hours of nursing interventions. Long term goal After 5 days of nursing interventions. cola and chocolates. 4. Goal was met. These drugs have rapid action and may decrease the blood pressure too rapidly. Observe skin colour. 8. 7. 5. 5. 3. capillary refill time and diaphoresis. thus allowing for changes in treatment regimen when required. the client had an adequate tissue perfusion to his body systems. Input and Output will give an indication of fluid balance or imbalance. Long term goal After 6 days of nursing interventions. Nursing intervention 1. Encourage patient to decrease intake of caffeine. Observe for . Caffeine is a cardiac stimulant and may adversely affect cardiac function. resulting in complications. 6. erythema. conduction defects and for heart rate. Suggest frequent position changes. the client will maintain adequate cardiac output and cardiac index. Evaluation Short term goal After 8 hours of nursing interventions.Monitor for sudden onset of chest pain. 4. 2. 2.To monitor baseline data. the client will have no elevation in blood pressure above normal limits and will maintain blood pressure within acceptable limits. Observe extremities for swelling. Monitor ECG for dysrrhythmias. temperature.volume. May indicate cyanide toxicity from increasing intracranial pressure. Rationale 1. dysrhythmias and conduction defects. rhythm. 7. tenderness and pain.Bed rest promotes venous statis which can increase the risk of thromboembolus 3. Decreased perfusion may result in dysrhythmias caused by decrease in oxygen. May indicate dissecting aortic aneurysm. 6. Monitor ECG for changes in rate. or every 5 minutes during active titration of vasoactive drugs.
decreased peripheral pulses. Nursing Diagnosis Activity intolerance related to the disease process evidenced by the patient verbalizing that they get tired easily when performing relatively easy tasks for example weeding the flower garden. Promotes prompt detection and facilitates prompt intervention. chest pain. tissue perfusion will be impaired and ischaemia can result. These drugs reduce the work . oedema. Administer medications that Rationale This helps in getting the base information of how the patient is performing. 9. walking. So that they give them more assistance with the exercises. shortness of breath. If treatment is too rapid and aggressive in decreasing the blood pressure. Promotes knowledge and compliance with treatment. visual changes. muscle cramps and nausea and vomiting. coldness and cyanosis. Evaluation The patient was able to tolerate exercises by the time they left the hospital. increased heart rate. So that they stop over straining their heart with heavy exercises. Instruct client in signs/symptoms to report to physician such as headache upon rising. increased blood pressure. Teach the patient relatively easy exercises like stretching. formation. Refer the patient to a physiotherapist so that they can continue to teach the patient on what exercises they are able to do with out over stressing the heart. 9. pallor. Goal The patient will be able to tolerate easy exercises and will be able to know what exercises they able to do by the time they leave the hospital Intervention Monitor the patients vital signs especially the blood pressure every two hours.
reduce the the hypertension as prescribed by a medical doctor. The patient´s basic needs were taken care of during their stay in hospital. Acts as a massage and allows blood flow and reduces bed sores. Reassure the patient that they would improve. Monitor the patient's diet especially salt intake which should be low. The patient did not develop oedema from altered tissue perfusion. Risk of altered tissue perfusion. like frusemide as prescribed by the medical doctor. and give them . Monitor patient fluid intake and out put by charting the input and output volumes. Change the This reduces bed patients bed sheets sores. Diuretics like Administer frusemide reduce medications for tissue perfusion or example diuretics oedema. there stay in hospital. increasing because of oedema. Altered health maintenance related to the disease process evidenced by the patient verbalizing “I can not do things like going The patient's basic needs will be taken of daily during there stay in the hospital. load of the heart. This provides base line information for the nurse. This reduces the anxiety of the patient so reduces the stress. To avoid fluid overload that would precipitate tissue perfusion or oedema. To monitor if the Weigh the patient patient weight is twice a day in the relatively constant morning and and is not evening. Give the patient a bed bath in the morning and evening. The patient will Monitor the vital not develop tissue signs of the oedema during patient. High salt diet increase tissue perfusion as water follows salt. thus improves care given to the patient.
J. 2008. Cardiac Nursing. Pearson Education Limited. ERB G. bathing by my self. ..” clean ones. 2007. SANDRA L.. process and practise. 841-842. BERMAN A. Fundamentals of Nursing: concepts... REFERENCE KOZIER B. 2nd ed p. LAKE R.to the toilet. UNDERHILL et al.B Lippincott Company.
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