Professional Documents
Culture Documents
Student Svetlana
Data Clustering
(Subjective and Objective)
89 y.o. female
Acute MI/CHF
Troponin=15.40
CK=417 K=2.9
BP 148/91
AP 80 irreg.
RR=24, 30 on
Kuksgauzen
Outcomes must be specific,
measurable, realistic, have a
time frame
Outcome 1
Pt will perform the level of
activity she can endure w/o
overexertion Q day.
Outcome 2
Date 04/14/2015
Nursing Actions
Assessment / Monitor
Assess current level of
activity Q day.
Assessment / Monitor
exertion
Assessment / Monitor
Assess for anxiety Q shift.
Nursing Diagnosis
Activity
intolerance R/T
decreased cardiac
output AEB
exertional
dyspnea.
Goal
Outcome 4
Intervention (Independent)
Pt will exhibit activity
tolerance with O2 sats >90% Evaluate the need for oxygen
Q day.
during activity Q day.
Outcome 5
Intervention (Independent)
Pt will exhibit
activity tolerance.
Outcomes
Nursing Actions
Outcome 6
Intervention (Independent)
Outcome 7
Intervention (Independent)
Outcome 8
Intervention (Independent)
and to support the use of constructive coping styles (emotionfocused, problem-focused coping) and/or relaxation strategies
(relaxation breathing, meditation, imagery, and music).
Emphasize to the pt that it is possible to live a productive life
with this chronic health problem. Working with the pt in setting
mutual goals is important to gradually increase activity levels.
Ref. Lewis, pg.92, 757, Gulanick, pg.333
Getting out of bed to use a commode or urinal does not stress the heart any
more than staying in bed to toilet. In addition, getting the patient out of bed
minimizes complications of immobility and is often preferred by the patient.
It is a form of an exercise. Exercise training (e.g., cardiac rehabilitation)
improves symptoms of chronic HF and has been found to be safe and to
improve the overall sense of well-being. Regular exercise will promote
activity tolerance.
Ref. Lewis, pg.782, Ackley, pg.182
Outcome 9
Outcome 10
Outcomes
Nursing Actions
Outcome 12
Pt will have pain level <5
(0-10) after taking
Morphine as per MDs
order.
Outcome 13
Pt will have HR=60-100
BPM, BP<120/80 mm Hg,
RR=12-20 breaths/min
when ambulating using a
walker Q ambulation.
Outcome 14
Administer Nitroglycerine 2% UD
ointment TD Q6H 1 inch as per
MDs order.
Goals for O2 therapy are to keep the SAO2 greater than 90% during rest,
sleep, and exertion, or the PaO2 greater than 60mm Hg. O2 is usually
administered to treat hypoxemia caused by a variety of problems, including
MI. Long-term continuous (more than 15 hr/day) O2 therapy improves
exercise capacity and mental status in hypoxemic pts.
Ref. Lewis, pg.589
Acetaminophen (Tylenol) is a nonopioid, nonsalisylate drug that has
analgesic and antipyretic effects. It is prescribed in treatment of mild pain
and fever. It inhibits the synthesis of prostaglandins that may serve as
mediators of pain and fever, primarily in CHF. Pain can have a profound
influence on pts quality of life and functioning. Decreasing pain will help pt
engage in physical and social activities, increase activity tolerance overtime.
Ref. Lewis, pg.122, 123. Daviss Drug Guide, pg.97
Scientific Rationale (reason your nursing actions will prevent, solve, or
lessen the stated nsg dx problem)
Morphine is an opioid analgesic prescribed for moderate/severe pain. It acts by
binding to opiate receptors in the CNS, altering the perception of and response to
painful stimuli while producing generalized CNS depression. Pain can have a
profound influence on pts quality of life and functioning. Decreasing pain will help
pt engage in physical and social activities, increase activity tolerance overtime.
Ref. Lewis, pg.123, Daviss Drug Guide, pg.861
In collaboration with other health care professionals, promote activity and exercise
by teaching the proper use of canes, walkers, or crutches, depending on the pts
condition. Holding on to a walker will allow pt avoid overexertion while
performing physical activity. Pts will benefit from exercise and activity in terms of
reduced mortality and morbidity, improved quality of life, and improved left
ventricular function.
Ref. Lewis, pg. 760, 764
Nitroglycerin is used in adjunct treatment of MI and treatment of HF associated
with MI. It increases coronary blood flow by dilating coronary arteries and
improving collateral flow to ischemic regions, produces vasodilation, decreases
left-ventricular pressure and end-diastolic volume. It will help increase cardiac
output, reduce BP, relieve/prevent angina attacks, which will help pt increase
activity tolerance. Ref. Daviss Drug Guide, pg.907
Teaching Outcome 15
Pt will verbalize
understanding of teaching
of a slow progression of
activity Q shift.
Teaching Outcome 16
Pt will demonstrate
understanding of signs of
overexertion Q shift.