b) Nursing Care Plans

Problem#1: Acute Pain
Cues
S> “Masakit ku salu ! as verbali"e# b$ t%e pt& O> '%e patient (a$ (anifest) * tac%$car#ia * tac%$pnea * sleep #isturbance * facial gri(aces * irritabilit$ >'%e patient (anifeste#) * +it% ox$gen %ooke# via nasal cannula regulate# at , lp( * +it% con#o(cat%eter attac%e# to urine bag * continuous car#iac (onitoring

Nursing Diagnosis
-cute .ain relate# to increase# lactic aci# pro#uction secon#ar$ to #ecrease# bloo# an# ox$gen suppl$ to ($ocar#iu(

Scientific Explanation
-cute .ain is t%e prioriti"e# proble( because it suggests isc%e(ia +%ic% is ver$ fatal& In acute ($ocar#ial infarction (ore co((onl$ kno+n as %eart attack! a (e#ical con#ition t%at occurs +%en t%e bloo# suppl$ to a part of t%e %eart is interrupte#! (ost co((onl$ #ue to rupture of a vulnerable pla/ue& '%e resulting isc%e(ia or ox$gen s%ortage causes #a(age an# potential #eat% of %eart tissue& 0ecause of #ecrease# bloo# an# ox$gen suppl$ to ($ocar#iu(! s%ifting fro( aerobic to anaerobic (etabolis( %appens t%us t%ere is an increase in lactic

Objectives
S%ort ter() -fter 1 %ours of NI! t%e patient +ill report relief of pain&

Nursing Interventions
>Establis% rapport >-ssess con#ition >Monitor 4S patient3s

Rationale
>to gain trust an# cooperation >to #eter(ine s5sx >to obtain baseline #ata >to #eter(ine precipitating factor5s > respirations (a$ be increase# as a result of pain an# associate anxiet$& >observations (a$5(a$ not be congruent +it% verbal reports in#icating nee# for furt%er evaluation >to provi#e non p%ar(acological (easures of relieving pain

Evaluation
S%ort ter() -fter 1 %ours of NI! t%e patient s%all %ave verbali"e# (et%o#s t%at provi#e relief&

2ong ter() -fter , #a$s of NI! t%e patient +ill #e(onstrate use of relaxation tec%ni/ues an# #ivertional activities as in#icate# for in#ivi#ual situation&

>.erfor( a co(pre%ensive assess(ent of pain >-ssess respirations! 0. an# %eart rate +it% eac% episo#es of c%est pain& >Observe nonverbal cues

2ong ter() -fter , #a$s of NI! t%e patient s%all %ave #e(onstrate# use of relaxation tec%ni/ues an# #ivertional activities as in#icate# for in#ivi#ual situation&

>.rovi#e co(fort (easures suc% as back rub

134

aci# pro#uction causing irritation to t%e %eart (uscle& '%is (ec%anis( causes a feeling of pain +%ic% (a$ activate t%e s$(pat%etic nervous s$ste( t%us causing tac%$pnea an# tac%$car#ia as a response& Due to t%e unco(fortable sensation! t%e patient (a$ be seen +it% facial gri(aces an# irritabilit$&

>.rovi#e a#e/uate rest perio#s >Maintain be# rest #uring pain! +it% position of co(fort! (aintain relaxing environ(ent to pro(ote cal(ness& >.repare for t%e a#(inistration of (e#ications! an# (onitor response to #rug t%erap$& Notif$ p%$sician if pain #oes not abate& >Revie+ +a$s lessen pain to

>to prevent fatigue an# pro(ote relaxation >to re#uce ox$gen consu(ption an# #e(an#! to re#uce co(peting sti(uli an# re#uces anxiet$

>pain control is a priorit$! as it in#icates isc%e(ia

>to +ellness >.rovi#e for in#ivi#uali"e# p%$sical t%erap$5exercise progra(s t%at can be continue# b$ t%e client +%en #isc%arge# >Discuss +it% SO6s7 +a$s in +%ic% t%e$ can assist client an# re#uce precipitating factors t%at (a$ cause or increase pain

pro(ote

>pro(otes active! not passive role

>to +ellness

pro(ote

135

>Instruct patient5fa(il$ in (e#ication effects! si#e*effects! contrain#ications an# s$(pto(s to report

> to pro(ote kno+le#ge an# co(pliance +it% t%erapeutic regi(en an# to alleviate fear of unkno+n

Problem#2: Ineffective airway clearance
Cues
S> '%e patient (a$ verbali"e) * #$spnea O> '%e patient (anifeste#) * pro#uctive coug% * fu""iness of t%e lung (arkings in bot% lungs * +it% ox$gen %ooke# via nasal cannula regulate# at , lp( * +it% con#o( cat%eter attac%e# to urine bag * continuous car#iac (onitoring > '%e patient (a$ (anifest) * c%anges in respirator$ rate or r%$t%(

Nursing Diagnosis
Ineffective air+a$ clearance r5t retaine# trac%eobronc%ial secretions -E0 presence of pro#uctive coug%

Scientific Explanation
.neu(onia is an infectious #isease c%aracteri"e# b$ infla((ator$ processes affecting t%e lung parenc%$(a& '%e inva#ing organis( causes s$(pto(s! in part! b$ provoking an overl$ exuberant i((une response in t%e lungs& Mucus pro#uction is increase# +%ic% plugs t%e air+a$ t%us furt%er co(pro(ising t%e air+a$ clearance of t%e patient& '%is event (a$ bring about c$anosis& In or#er to co(pensate! t%e patient (a$ breat%e

Objectives
S%ort ter() -fter 1 %ours of NI! t%e patient +ill #e(onstrate be%aviors to i(prove or (aintain air+a$ patenc$&

Nursing Interventions
>Establis% rapport >-ssess con#ition >Monitor 4S >-uscultate soun#s breat% patient3s

Rationale
>to gain trust an# cooperation >to #eter(ine s5sx >to obtain baseline #ata > to note presence of a#ventitious breat% soun#s > use of accessor$ (uscles to breat%e in#icates an# abnor(al increase in +ork of breat%ing > to i#entif$ infectious process an# pro(ote ti(el$ interventions

Evaluation
S%ort ter() -fter 1 %ours of NI! t%e patient s%all %ave verbali"e# (et%o#s t%at provi#e relief&

2ong ter() -fter 1 #a$s of NI! t%e patient +ill #e(onstrate absence5re#uction of congestion +it% breat% soun#s clear! respirations noiseless an# i(prove# ox$gen exc%ange&

>-ssess respirator$ (ove(ents an# use of accessor$ (uscles

>Observe for signs an# s$(pto(s of infection

2ong ter() -fter , #a$s of NI! t%e patient s%all %ave #e(onstrate# use of relaxation tec%ni/ues an# #ivertional activities as in#icate# for in#ivi#ual situation&

136

* #i(inis%e# or a#ventitious breat% soun#s * c$anosis

rapi#l$ in or#er to bring in (ore ox$gen t%us (anifesting c%anges in respirator$ rate or r%$t%(&

>Monitor c%est ra#iograp% reports >8se positioning b$ placing on a se(i* %ig% fo+ler3s position >Elevate %ea# of be# or c%ange position ever$ , %ours an# prn

>to (onitor severit$ of #isease

t%e t%e

>to facilitate lung expansion > to take a#vantage of gravit$ #ecreasing pressure on t%e #iap%rag( an# en%ancing #rainage or ventilation to #ifferent lung seg(ents >to ai# in (obili"ation secretions >to secretions t%e of

>Maintain a#e/uate %$#ration +%en possible > .erfor( nebuli"ation an# C.' as in#icate# >Institute suctioning as nee#e#

loosen

> to clear air+a$ +%en secretions are blocking t%e air+a$ > to %ave patent air+a$ t%roug% artificial (eans >to provi#e p%ar(acological (anage(ent to treat con#ition

>8se p%ar$ngeal p%ar$ngeal as nee#e# >-#(inister (e#ication prescribe#

5

naso* oro* air+a$

as

137

>-#(inister analgesics prescribe#

as

>to (axi(i"e coug% +%en pain is in%ibiting effort > to pro(ote continuit$ of care

>Refer to appropriate support groups

Problem#3: Impaire !as "#c$ange
Cues
S> '%e patient (a$ verbali"e) * #$spnea O> '%e patient (anifeste#) * pro#uctive coug% * fu""iness of t%e lung (arkings in bot% lungs * +it% ox$gen %ooke# via nasal cannula regulate# at , lp( * +it% con#o( cat%eter attac%e# to urine bag * continuous car#iac (onitoring > '%e patient (a$ (anifest) * confusion * let%arg$ * abnor(al -093s

Nursing Diagnosis
I(paire# 9as Exc%ange r5t collection of secretions affecting ox$gen exc%ange across alveolar (e(brane

Scientific Explanation
.neu(onia bot% affects ventilation an# #iffusion& -n infla((ator$ reaction can occur in t%e alveoli! pro#ucing exu#ates t%at interfere in t%e #iffusion of ox$gen an# carbon #ioxi#e& :%ite bloo# cells! (ostl$ neutrop%ils! also (igrate into t%e alveoli an# fill t%e nor(all$ air* containing spaces& -reas of t%e lungs are not a#e/uatel$ ventilate# because of secretions an# (ucosal e#e(at%at cause partial occlusion of t%e bronc%i or alveoli! +it% a resultant

Objectives
S%ort ter() -fter 1 %ours of NI! t%e patient +ill #e(onstrate be%aviors to i(prove or (aintain air+a$ patenc$&

Nursing Interventions
>Establis% rapport >-ssess con#ition >Monitor 4S >-uscultate soun#s breat% patient3s

Rationale
>to gain trust an# cooperation >to #eter(ine s5sx >to obtain baseline #ata >to note presence of a#ventitious breat% soun#s >use of accessor$ (uscles to breat%e in#icates an# abnor(al increase in +ork of breat%ing >to i#entif$ infectious process an# pro(ote ti(el$ interventions

Evaluation
S%ort ter() -fter 1 %ours of NI! t%e patient s%all %ave #e(onstrate# be%aviors to i(prove or (aintain air+a$ patenc$&

2ong ter() -fter 1 #a$s of NI! t%e patient +ill #e(onstrate absence or re#uction of congestion +it% breat% soun#s clear! respirations noiseless an# i(prove# ox$gen exc%ange&

>-ssess respirator$ (ove(ents an# use of accessor$ (uscles

>Observe for signs an# s$(pto(s of infection

2ong ter() -fter 1 #a$s of NI! t%e patient s%all %ave #e(onstrate# absence or re#uction of congestion +it% breat% soun#s clear! respirations noiseless an# i(prove# ox$gen exc%ange&

138

* c$anosis

#ecrease in alveolar ox$gen tension& -n i(balance in ox$gen an# carbon #ioxi#e exc%ange (a$ be evi#ent in t%e patient3s arterial bloo# gases& #ecrease in ox$gen suppl$ (a$ cause confusion an# let%arg$&

>Monitor c%est ra#iograp% reports >Evaluate oxi(eter #eter(ine ox$genation pulse to

>to (onitor severit$ of #isease

t%e t%e

&

>to assess respirator$ insufficienc$ >to facilitate lung expansion > to take a#vantage of gravit$ #ecreasing pressure on t%e #iap%rag( an# en%ancing #rainage or ventilation to #ifferent lung seg(ents >to ai# in (obili"ation secretions t%e of

>8se positioning b$ placing on a se(i* %ig% fo+ler3s position >Elevate %ea# of be# or c%ange position ever$ , %ours an# prn

>Maintain a#e/uate %$#ration +%en possible +it% precautions on flui# overloa# >.erfor( nebuli"ation an# C.' as in#icate# >Institute suctioning as nee#e#

>to secretions

loosen

> to clear air+a$ +%en secretions are blocking t%e air+a$ > to %ave patent air+a$ t%roug%

>8se p%ar$ngeal

5

naso* oro*

139

p%ar$ngeal air+a$ as nee#e# >Encourage a#e/uate rest an# li(it activities to +it%in client tolerance >-#(inister (e#ication prescribe# >-#(inister analgesics prescribe# as

artificial (eans > %elps li(it ox$gen nee#s5consu(ption

>to provi#e p%ar(acological (anage(ent to treat con#ition >to (axi(i"e coug% +%en pain is in%ibiting effort > to pro(ote continuit$ of care

as

>Refer to appropriate support groups

Problem#%: Ineffective tissue perfusion &car iac) r't myocar ial cell wall in(ury
Cues
S> '%e patient (a$ verbali"e) * sense of i(pen#ing #oo( O> '%e patient (anifeste#) * #ilate# left ventricle +it% seg(ental +all (otion abnor(alities * severel$ #epresse# left ventricular s$stolic function +it%

Nursing Diagnosis
Ineffective tissue perfusion 6car#iac7 r5t ($ocar#ial cell +all injur$

Scientific Explanation
Ineffective tissue perfusion is a #ecrease in Ox$gen resulting in t%e failure to nouris% t%e tissues an# capillaries& M$ocar#ial Infarction occurs +%en insufficient bloo# suppl$ reac%es t%e %eart t%us causing #a(age to t%e %eart (uscle& .ossible

Objectives
S%ort ter() -fter 1 %ours of NI! t%e patient +ill verbali"e un#erstan#ing of con#ition an# t%erap$ regi(en an# #e(onstrate lifest$le c%anges to i(prove circulation&

Nursing Interventions
>Establis% rapport >-ssess con#ition >Monitor 4S >Revie+ baseline -09s! electrol$tes! 08N5Cr! car#iac en"$(es > -ssess for patient3s

Rationale
>to gain trust an# cooperation >to #eter(ine s5sx >to obtain baseline #ata > to note #egree of i(pair(ent5organ involve(ent > Earl$ #etection of

Evaluation
S%ort ter() -fter 1 %ours of NI! t%e patient s%all %ave #e(onstrate# be%aviors to i(prove or (aintain air+a$ patenc$&

2ong ter()

2ong ter() -fter 1 #a$s of NI!

140

at least gra#e ; left ventricular #iastolic #$sfunction * elevate# C<=M0 levels 61>&1 ng5#l7 * %gb levels belo+ nor(al 6?,1 g5#l7 * %ct levels belo+ nor(al 6@&;A g5#l7 * c%est pain * +it% ox$gen %ooke# via nasal cannula regulate# at , lp( * +it% con#o( cat%eter attac%e# to urine bag * continuous car#iac (onitoring > '%e patient (a$ (anifest) * confusion * let%arg$ * abnor(al -093s * c$anosis

contributing factors inclu#e #ilation of t%e left ventricle +%ic% in%ibits its nor(al pu(ping abilit$! t%us re#ucing t%e bloo# suppl$ t%at t%e %eart an# tissues #e(an#& -lso! in cases of lo+ %e(oglobin an# %e(atocrit levels! t%e tissues +oul# not receive t%e a#e/uate a(ount of ox$gen t%e$ nee#! an# if left untreate# +oul# result to isc%e(ia +%ic% (a$ lea# to an infarction& Certain car#iac (arkers (a$ be use# to #iagnose an infarction suc% as C<*M0& Suc% +oul# confir( an infarction if levels are seen elevate#&

-fter 1 #a$s of NI! t%e patient +ill #e(onstrate increase# perfusion as in#ivi#uall$ appropriate&

possible causative factors relate# to te(poraril$ i(paire# arterial bloo# flo+ > Maintain opti(al car#iac output

cause facilitates pro(pt! effective treat(ent& > '%is ensures a#e/uate perfusion of vital organs& Support (a$ be re/uire# to facilitate perip%eral circulation 6e&g&! elevation of affecte# li(b! antie(bolis( #evices7 > to conserve energ$ an# lo+ers tissue O, #e(an#s > to (axi(i"e tissue perfusion

t%e patient s%all %ave #e(onstrate# absence or re#uction of congestion +it% breat% soun#s clear! respirations noiseless an# i(prove# ox$gen exc%ange& &

> Encourage /uiet! restful at(osp%ere > Caution patient to avoi# activities t%at increase car#iac +orkloa#& Encourage earl$ a(bulation! if possible > Explain possible factors t%at (a$ boost t%e occurrence of ineffective tissue perfusion > I#entif$ c%anges r5t s$ste(ic or perip%eral alterations in circulation >-#(inister

> 'o i(pose a+areness on t%e patient an# SO

> 'o evaluate if furt%er co(plications +ill occur >Drugs t%at i(prove

141

(e#ications caution

+it%

perfusion also carr$ t%e risk of a#verse response >Infor(ation necessar$ for client to (ake infor(e# c%oices about re(e#ial risk factors an# co((it(ent to lifest$le c%anges! as appropriate! to prevent co(plications or (anage s$(pto(s +%en present >Bacilitates (anage(ent of %$pertension +%ic% is a (ajor risk factor in t%e #a(age of bloo# vessels or organ #$sfunction&

>Discuss in#ivi#ual risk factors

>Instruct in bloo# pressure (onitoring at %o(e

Problem#): *ecrease Car iac +utput
Cues
S> t%e patient (a$ verbali"e) * s%ortness of breat% 5#$spnea * fatigue * anxiet$ O> '%e patient (anifeste#) * #ilate# left ventricle +it%

Nursing Diagnosis
Decrease# car#iac output r5t altere# stroke volu(e

Scientific Explanation
'%e %$poxic tissue in ($ocar#ial infarction +it%in t%e bor#er "one (a$ beco(e a site for generating arr%$t%(ias& Infracte# tissue #oes not contribute to tension generation #uring s$stole! an# t%erefore can alter

Objectives
S%ort ter() -fter 1 %ours of NI! t%e patient +ill participate in activities t%at #ecrease t%e +orkloa# of t%e %eart suc% as stress (anage(ent or t%erapeutic (e#ication regi(en

Nursing Interventions
>Establis% rapport >-ssess con#ition >Monitor 4S >Monitor EC9 for patient3s

Rationale
> to gain trust an# cooperation > to #eter(ine signs an# s$(pto(s > to obtain baseline #ata > #ecrease in

Evaluation
S%ort ter() -fter 1 %ours of NI! t%e patient s%all %ave participate# in activities t%at #ecrease t%e +orkloa# of t%e %eart suc% as stress (anage(ent or t%erapeutic

142

seg(ental +all (otion abnor(alities * severel$ #epresse# left ventricular s$stolic function +it% at least gra#e ; left ventricular #iastolic #$sfunction * +it% ox$gen %ooke# via nasal cannula regulate# at , lp( * +it% con#o(cat%eter attac%e# to urine bag * continuous car#iac (onitoring '%e patient (a$ (anifest) * #$sr%$t%(ias * EC9 c%anges * c$anosis * pallor * prolonge# capillar$ refill * #ecrease# perip%eral pulses * variations in bloo# pressure rea#ings

ventricular s$stolic an# #iastolic function an# #isrupt electrical activit$ +it%in t%e %eart& :it%out i(prove(ent! t%e %eart (uscles (a$ un#ergo re(o#eling suc% as %$pertrop%$! losing its nor(al pu(ping abilit$! t%us (a$ cause ina#e/uate bloo# to (eet t%e nee#s of t%e bo#$3s tissues& Car#iac output an# tissue perfusion are interrelate#! t%us a #ecrease in car#iac output (a$ bring about c$anosis! pallor an# prolonge# capillar$ refill& '%ere (a$ also be fatigue an# s%ortness of breat% as t%ere is not enoug% ox$gen supplie# to t%e tissues&

progra(

#$srr%$t%(ias! con#uction #efects an# for %eart rate

car#iac output (a$ result in c%anges in car#iac perfusion causing #$sr%$t%(ias > to note effectiveness (e#icines for of

(e#ication regi(en progra( 2ong ter() -fter 1 #a$s of NI! t%e patient s%all %ave #ispla$e# %e(o#$na(ic stabilit$ -E0 nor(ali"ation of EC9 tracings an# bloo# pressure rea#ings

2ong ter() -fter 1 #a$s of NI! t%e patient +ill #ispla$ %e(o#$na(ic stabilit$ -E0 nor(ali"ation of EC9 tracings an# bloo# pressure rea#ings

>Monitor car#iac r%$t%(s continuousl$ >Encourage patient to #ecrease intake of caffeine! cola an# c%ocolates >Observe skin color! te(perature! capillar$ refill ti(e an# #iap%oresis

> caffeine is a car#iac sti(ulant an# (a$ a#versel$ affect car#iac function > perip%eral vasoconstriction (a$ result in pale! cool! cla(($ skin! +it% prolonge# capillar$ refill ti(e #ue to car#iac #$sfunction an# #ecrease# car#iac output > to (aintain a#e/uate nutrition an# flui# balance > to provi#e a#e/uate ox$genation > to +ellness for

>Monitor intake an# output an# calculate ,1 %our flui# balance >-#(inister supple(ental ox$gen as in#icate# >-#(inister (e#icines prescribe# b$ p%$sician as t%e

pro(ote

>.ro(ote a#e/uate

>

to

#ecrease

143

rest b$ #ecreasing sti(uli provi#ing /uiet environ(ent >Encourage c%anging positions slo+l$! #angling legs before stan#ing >Instruct client C fa(il$ on flui# an# #iet re/uire(ents an# restrictions of so#iu(

ox$gen consu(ption > to prevent occurrence of ort%ostatic %$potension > restrictions can assist +it% #ecrease in flui# retention an# %$pertension! t%ereb$ i(proving car#iac output > pro(otes kno+le#ge an# co(pliance +it% #rug regi(en

> instruct client an# fa(il$ on (e#ications! si#e effects! contrain#ications an# signs to report

Problem#,: -is. for Aspiration
Cues
S> O O> t%e patient (anifeste#) * +it% pro#uctive coug% * +it% presence of crackles on lo+er lobe of t%e rig%t lung * +it% ox$gen %ooke# via nasal cannula regulate# at

Nursing Diagnosis
Risk for -spiration r5t presence of retaine# secretions

Scientific Explanation
.neu(onai is a serious infection t%at affects t%e airsacs +it% acco(pan$ing secretions t%at (a$ be expectorate#& Su##en coug%ing (a$ (obili"e t%e secretions an# (a$ reac% t%e air+a$ +%ic% (a$ cause #istress to t%e

Objectives
S%ort ter() -fter 1 %ours of NI! t%e patient +ill be free fro( aspiration -E0 %aving a patent air+a$

Nursing Interventions
>Establis% rapport >-ssess con#ition >Monitor 4S > Monitor level of consciousness patient3s

Rationale
>to gain trust an# cooperation >to #eter(ine signs an# s$(pto(s >to obtain baseline #ata& > - #ecrease# level of consciousness is a pri(e risk factor

Evaluation
S%ort ter() -fter 1 %ours of NI! t%e patient s%all be free fro( aspiration -E0 %aving a patent air+a$

2ong ter()

144

, lp( * +it% con#o( cat%eter attac%e# to urine bag * continuous car#iac (onitoring >t%e patient (a$ (anifest) * respirator$ #istress

patient3s breat%ing +%ic% is fatal& 8suall$ +%en so(eone aspirates t%e$ coug% in an atte(pt to clear t%e foo# or flui# out of t%eir lungs&

-fter , #a$s of NI! t%e patient +ill experience no aspiration -E0 noiseless respirations an# clear breat% soun#s

for aspiration > <eep suction setup available an# use as nee#e# > Notif$ t%e p%$sician or ot%er %ealt% care provi#er i((e#iatel$ of note# #ecrease in coug% an#5or gag reflexes or #ifficult$ in s+allo+ing >-ssist +it% postural #rainage > '%is is necessar$ to (aintain a patent air+a$ > Earl$ intervention protects t%e patient3s air+a$ an# prevents aspiration

2ong ter() -fter , #a$s of NI! t%e patient s%all %ave experience# no aspiration -E0 noiseless respirations an# clear breat% soun#s

>to (obili"e t%ickene# secretions +%ic% (a$ cause i(pair(ent in s+allo+ing >t%e reste# (a$ %ave #ifficult$ s+allo+ing client less in

>.rovi#e a perio# prior fee#ing ti(e

rest to

>Mini(i"e use of se#atives5%$pnotics +%enever possible& >.rovi#e infor(ation on t%e effect of aspiration on t%e lungs

>t%ese agents can i(pair coug%ing or s+allo+ing >severe coug%ing an# c$anosis associate# +it% eating or #rinking or c%anges in vocal /ualit$ after s+allo+ing in#icates onset of respirator$ s$(pto(s associate# +it% aspiration an# re/uires i((e#iate

145

interventions& >Refer >to pro(ote continuit$ of care

Problem#/: An#iety
Cues
SD O OD pt& (anifeste# *+it% goo# skin turgor *+it% pale palpebral conjunctiva *+it% capillar$ refill , secon#s * Col# cla(($ skin *+it% ox$gen %ooke# via nasal cannula regulate# at , lp( *+it% con#o( cat%eter attac%e# to urine bag *continuous car#iac (onitoring

Nursing Diagnosis
-nxiet$ r5t perceive# 5actual t%reat of #eat%! pain! possible lifest$le c%anges b$ restlessness

Scientific Explanation
Coping +it% t%e pain an# e(otional trau(a is #ifficult& .atient (a$ fear #eat% an# or be anxious about i((e#iate environ(ent& Ongoing anxiet$ 6relate# to concerns about i(pact of %eart attack on future lifest$le! (atters left unatten#e#5unresolve# an# effects of illness on fa(il$7 (a$ be present in var$ing #egrees for so(e ti(e an# (a$be (anifeste# b$ s$(pto(s of #epression suc% as sleep #isturbance an# restlessness&

Objectives
S%ort ter() -fter ;*1 %ours of nursing intervention pt +ill i#entif$ %ealt%$ +a$s to #eal +it% an# express anxiet$&

Nursing Interventions
>Establis% rapport >-ssess patient3s con#ition >Monitor vital signs

Rationale
>'o gain trust an# cooperation >'o (onitor p%$siologic con#ition >'o %ave baseline #ata >to %elp pt& regain control of o+n be%avior

Evaluation
S%ort ter() -fter ;*1 %ours of nursing intervention pt s%all %ave i#entifie# %ealt%$ +a$s to #eal +it% an# express anxiet$&

2ong ter() -fter ; #a$s of nursing intervention pt& +ill appear relaxe# an# report anxiet$ is re#uce# to a (anageable level&

>Observe for verbal5non*verbal signs of anxiet$! an# sta$ +it% t%e pt& Intervene if pt& #ispla$s #estructive be%avior& >Maintain confi#ent (anner 6+it%out false reassurance7 >Orient pt5SO to routine proce#ures an# expecte# activities >.rovi#e privac$ for pt& an# SO&

2ong ter() >%onest explanation can alleviate anxiet$ >pre#ictabilit$ an# participation can #ecrease anxiet$ >-llo+s nee#e# ti(e for personal expression of -fter ; #a$s of nursing intervention pt& s%all %ave appeare# relaxe# an# reporte# anxiet$ is re#uce# to a (anageable level&

.t& (a$ (anifest) *Sleep #isturbance *Restlessness *'ac%$car#ia *'ac%$pnea

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feelings! (a$ en%ance (utual support an# pro(ote (ore a#aptive be%aviors& >.rovi#e rest perio#s5uninterrupte# sleep! /uiet surroun#ings& >Raise si#e rails >E(p%asi"e i(portance of a#e/uate nutritional intake& >Regulate an# (onitor I4 flui#& >-#(inister (e#ications as or#ere# > 'o (aintain general goo# %ealt%& >'o pro(ote flui# (anage(ent& >Bor opti(u( +ellness >Conserves energ$ an# en%ances coping abilities& >to provi#e safet$

Problem#0: 1atigue
Cues
S > “agad ako napapagod, tulad pag maglalakad at maliligo ako O> '%e patient (anifests) • col# cla(($ skin • #r$ skin • +eakness even +it% si(ple activities

Nursing Diagnosis
Batigue r5t #ecrease ox$genation an# perfusion ,E pul(onar$ congestion

Scientific Explanation
Batigue is an over+%el(ing sustaine# sense of ex%austion an# #ecrease# capacit$ for p%$sical an# (ental +ork at usual level& Insulin is secrete# b$ beta cells! +%ic% are one of four t$pes of cells

Objectives
S%ort ter() -fter ; %ours of nursing interventions patient +ill be able to perfor( -D2s an# participate in #esire# activities at level of abilit$& 2ong ter()

Nursing Interventions
>Establis% rapport

Rationale
>to gain t%e trust an# cooperation of t%e patient& >to %ave a general %ealt% status of t%e patient& >to obtain baseline #ata

Evaluation
S%ort ter() -fter ; %ours nursing interventions patient s%all %ave perfor(e# -D2s an# participate in #esire# activities at level of abilit$&

>-ssess con#ition

patient3s

> Monitor vital signs

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• capillar$ refill F ; sec& • crackles on t%e rig%t lung fiel# • v5s taken an# recor#e# as follo+s) 'D;GEC! RRD,? cp(! .RDGH bp(! 0.D?;@5I@ ((Jg&

'%e patient (anifests) • restlessness • tac%$pnea

(a$

in t%e islets of 2anger%ans in t%e pancreas! insulin is a storage %or(one! +%en a person eats a (eal! insulin secretion increases an# (ove glucose to t%e bloo#! into (uscle! liver! an# fat cells& Due to DM t$pe , t%ere is insulin resistance or i(paire# insulin secretion +%ic% results in t%e in%ibition of t%e transport an# (etabolis( of glucose into energ$ lea#ing to eas$ fatigabilit$ -E0 b$ pt& +eakness even #oing activities of #ail$ living&

-fter ? #a$ of nursing interventions patient +ill report i(prove sense of energ$&

> Instruct patient to increase flui# intake up to I* ?@ glasses of +ater > Instruct to sit instea# of stan#ing #uring activities or s%o+er >Instruct patient to increase intake of vita(in or iron supple(entation like juice >Stretc% linens >-ssist +it% self* care nee#s like keep be# in lo+ position >Stress proper %an# +as%ing >-#(inister as or#ere#& #rugs

> a source of energ$ an# to prevent #e%$#ration > to energ$ conserve

2ong ter() -fter ? #a$ of nursing interventions patient s%all %ave reporte# i(prove sense of energ$&

> to pro(ote overall %ealt% (easures&

>to provi#e co(fort >'o energ$ conserve

>to prevent infection& > for +ellness opti(u(

Problem#2: -is. for Infection
Cues
S> O O> '%e patient (anifeste#) * pro#uctive coug% * +it% ox$gen %ooke# via nasal cannula regulate#

Nursing Diagnosis
Risk for Infection r5t ina#e/uate pri(ar$ #efenses 6#ecrease# ciliar$ action7

Scientific Explanation
8pper air+a$ c%aracteristics nor(all$ prevent potentiall$ infectious particles fro( reac%ing t%e sterile lo+er respirator$ tract& .neu(onia

Objectives
S%ort ter() -fter , %ours of nursing intervention patient +ill i#entif$ interventions to prevent5re#uce risk5sprea# of5secon#ar$

Nursing Interventions
>Establis% rapport >-ssess con#ition >Monitor 4S patient3s

Rationale
>to gain trust an# cooperation >to #eter(ine s5sx >to obtain baseline #ata

Evaluation
S%ort ter() -fter , %ours of NI! t%e patient s%all %ave i#entifie# interventions to prevent5re#uce risk5sprea#

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at , lp( * +it% con#o( cat%eter attac%e# to urine bag * continuous car#iac (onitoring > '%e patient (a$ (anifest) * fever * c%ills * DO0 * increase in RR! .R * increase in :0C levels an# neutrop%ils

involves t%e infla((ation of t%e lung parenc%$(a +%ic% eventuall$ lea#s to a #ecrease# ciliar$ action an# (a$ furt%er lea# to stasis of respirator$ secretions t%e client is at risk for t%e sprea# of infection since t%e continuous pro#uction of (ucus secretions is a perfect bree#ing place for (icroorganis(s& -n# if t%e bo#$ #oes not cope +ell t%e infection (a$ sprea# to t%e rest of t%e bo#$&

infection& >Obtain appropriate tissue5flui# speci(ens 2ong ter() -fter 1 #a$s of NI! t%e patient +ill ac%ieve ti(el$ resolution of current infection +it%out co(plications& >Stress proper %an# +as%ing tec%ni/ues b$ all care givers bet+een t%erapies an# client >Encourage coug%ing C! position c%ange >Monitor client3s visitors or caregivers for presence of respirator$ illnesses& Offer (asks5tissues to client5visitors +%o are coug%ing or snee"ing >Encourage #eep breat%ing! coug%ing an# fre/uent position c%anges >for observation for culture an# sensitivit$ testing > it is a first line #efense against nosoco(ial infection or cross conta(ination >for (obili"ation of respirator$ secretions >to li(it exposures! t%us re#uce cross conta(ination

of5secon#ar$ infection&&

2ong ter() -fter 1 #a$s of NI! t%e patient s%all %ave ac%ieve# ti(el$ resolution of current infection +it%out co(plications

>for (obili"ation of secretions an# prevention of aspiration or respirator$ infection > Bacilitates %ealing process an# en%ances natural resistance& >to #eter(ine effectiveness of t%erap$ an# presence of si#e effects

> Encourage a#e/uate rest balance# +it% (o#erate activit$& .ro(ote a#e/uate nutritional intake >-#(inister or (onitor (e#ication regi(en an# note client3s response

149

>-#(inister prop%$lactic as in#icate#

antibiotic

>to correct nor re#uce existing risk factors > Dela$e# recover$ or increase in severit$ of s$(pto(s suggests resistance to antibiotics or secon#ar$ infection >to +ellness pro(ote

> Investigate su##en c%anges5#eterioration in con#ition! suc% as increasing c%est pain! extra %eart soun#s! altere# sensoriu(! recurring fever! c%anges in sputu( c%aracteristics >Revie+ in#ivi#ual nutritional nee#s! appropriate exercise progra( an# nee# for rest >E(p%asi"e nee#s for taking antiviral or antibiotics as #irecte#

>.re(ature #iscontinuation of treat(ent +%en client feels +ell (a$ result in return of infection an# (a$ potentiate #rug*resistant strains >to increase a+areness of an# prevention of ao((unicable #iseases

>.rovi#e infor(ation or involve in appropriate co((unit$ an# national e#ucation progra(s

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Problem#13: Activity Intolerance
Cues
S> '%e pt& (a$ verbali"e) * exertional #$spnea or #isco(fort * reports of fatigue or +eakness O> t%e patient (anifeste#) * nee# for assistance upon (ove(ent * li(ite# range of (otion * +it% ox$gen %ooke# via nasal cannula regulate# at , lp( * +it% con#o(cat%eter attac%e# to urine bag * continuous car#iac (onitoring '%e patient (a$ (anifest) * tac%$pnea an# increase# bloo# pressure upon perfor(ance of activities * pallor * c$anosis * isc%e(ic EC9

Nursing Diagnosis
-ctivit$ Intolerance r5t car#iac #$sfunction! i(balance in ox$gen suppl$ an# consu(ption as evi#ence# b$ s%ortness of breat% upon exertion

Scientific Explanation
'%e un#erl$ing (ec%anis( of a %eart attack is t%e #estruction of %eart (uscle cells #ue to a lack of ox$gen& If t%ese cells are not supplie# +it% sufficient ox$gen b$ t%e coronar$ arteries to (eet t%eir (etabolic #e(an#s! t%e$ #ie b$ a process calle# infarction& '%e #ecrease in bloo# suppl$ (a$ bring about necrosis of t%e %eart (uscle +%ic% +oul# (ake it +eaker as a pu(p& -s a result! t%e pu(ping (ec%anis( of t%e %eart +ill be ineffective t%us giving t%e in#ivi#ual an insufficient suppl$ of bloo#! bringing about an inefficient suppl$ of ox$gen to t%e tissues t%us lea#ing to eas$ fatigabilit$ upon si(ple exertions& If

Objectives
S%ort ter() -fter 1 %ours of NI! t%e patient +ill use i#entifie# tec%ni/ues to increase activit$ tolerance&

Nursing Interventions
>Establis% rapport >-ssess con#ition >Monitor 4S patient3s

Rationale
>to gain trust an# cooperation >to #eter(ine signs an# s$(pto(s >c%anges in 4S assist +it% (onitoring p%$siologic responses to increase in activit$& >alleviation of factors t%at are kno+n to create intolerance can assist +it% #evelop(ent of an activit$ level progra( > to %elp give t%e patient a feeling of self*+ort% an# +ell* being > to #ecrease energ$ expen#iture an# fatigue > to (aintain joint (obilit$ an# (uscle

Evaluation
S%ort ter() -fter 1 %ours of NI! t%e patient s%all %ave use# i#entifie# tec%ni/ues to increase activit$ tolerance&

2ong ter() -fter 1 #a$s of NI! t%e patient +ill be able to increase an# ac%ieve #esire# activit$ level! progressivel$! +it% no intolerance s$(pto(s note#! suc% as respirator$ co(pro(ise&

>I#entif$ causative factors lea#ing to intolerance of activit$

>Encourage patient to assist +it% planning activities! +it% rest perio#s as necessar$ >Instruct patient in energ$ conservation tec%ni/ues >-ssist +it% active or passive ROM

2ong ter() -fter 1 #a$s of NI! t%e patient s%all %ave increase# an# ac%ieve# #esire# activit$ level! progressivel$! +it% no intolerance s$(pto(s note#! suc% as respirator$ co(pro(ise

151

c%anges

t%e con#ition beco(es severe! t%e patient (a$ %ave inabilit$ in perfor(ing activities an# s%o+ c%anges in vital signs upon perfor(ance of activities& -lso! t%ere coul# be c%anges in t%e EC9 s%o+ing signs of isc%e(ia&

exercises >-ssist patient +it% a(bulation! as or#ere#! +it% progressive increases as patient3s tolerance per(its >-#just activities accor#ing to patient3s tolerance >.lan care +it% rest perio#s bet+een activities >.rovi#e positive at(osp%ere! +%ile ackno+le#ging #ifficult$ of t%e situation for t%e patient >-ssist patient +it% activities an# (onitor use of assistive #evices >.ro(ote co(fort (easures an# provi#e for relief of pain >.rovi#e referral to ot%er #isciplines as in#icate# > Instruct client5SO

tone > to gra#uall$ increase t%e bo#$ to co(pensate for t%e increase in overloa#

> to prevent overexertion > to re#uce fatigue

> %elps to (ini(i"e frustration! rec%annel activities

> to protect client fro( injur$

> to en%ance abilit$ to participate in activities > to #evelop in#ivi#uall$ appropriate treat(ent regi(en > (a$ in#icate a

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in (onitoring response to activit$ an# recogni"ing signs an# s$(pto(s

nee# in alteration of activities

Problem#11: 4elf Care *eficit r't wea.ness
Cues
S>K O> '%e (anifests) patient

Nursing Diagnosis
Self care #eficit relate# to +eakness or tire#ness&

Scientific Explanation
'%e nurse (a$ encounter t%e patient +it% self * care #eficit in t%e %ospital& '%e #eficit (a$ be a result of transient li(itations! suc% as t%ose one (ig%t experience +%ile recovering fro( surger$ or t%e result of t%e progressive #eterioration t%at ero#es t%e in#ivi#ual3s abilit$ or +illingness to perfor( t%e activities re/uire# to care for %i(self& Careful exa(ination of t%e patient3s #eficit is re/uire# in or#er to be certain t%at t%e patient is not failing self*care because of lack of (aterials +it% arranging t%e environ(ent to suit t%e patient3s p%$sical li(itations&

Objectives
S%ort ter() -fter ; %ours of nursing interventions patient +ill be able to verbali"e un#erstan#ing on t%e i(portance of self*care& 2ong ter() -fter ? #a$ of nursing interventions patient +ill safel$ perfor( self*care activities&

Nursing Interventions
>Establis% rapport

Rationale
>to gain t%e trust an# cooperation of t%e patient& >to %ave a general %ealt% status of t%e patient& >to obtain baseline #ata > to encourage an# buil# on successes

Evaluation
S%ort ter() -fter ; %ours nursing interventions patient s%all %ave verbali"e# t%e i(portance of self* care&

• col# cla(($ skin • goo# skin turgor • capillar$ refill F ; sec& • irritabilit$ • +eakness +%en taking a bat% • eas$ fatigabilit$ even onl$ #oing -D2s

>-ssess con#ition

patient3s

> Monitor vital signs >-ssist +it% necessar$ a#aptations to acco(plis% -D2s > -rrange for assistive #evices as necessar$ 6seat5grab bars7 >Instruct patient to increase flui# intake up to I* ?@ glasses of +ater >Encourage foo# c%oices reflecting in#ivi#ual likes an# abilities t%at (eet nutritional nee#s

> to prevent injur$

2ong ter() -fter ? #a$ of nursing interventions patient s%all %ave perfor(e# safel$ self*care activities&

'%e patient (anifests) • restlessness

(a$

> to prevent #e%$#ration an# a source of energ$ > to increase energ$

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>Stretc% linens >Stress proper %an# +as%ing >Instructe# patient to perfor( goo# %$giene >-#(inister as or#ere#& #rugs

>to provi#e co(fort >to prevent infection& >'o relieve patient an# provi#e co(fort > for +ellness opti(u(

154