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Prioritized Nursing Diagnosis

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

Pulse 90, 115 on


exersion
Pt c/o SOBE
BUN=30 Cr=1.6
Non-pitting edema
CXR-cardiomegaly
ECHO-ac. MI/CHF
Anxiety
Afib

Pt will continue the activity or Observe the response to


stop it if HR increases of
activity Q shift.
more than 20 BPM Q shift.
Outcome 3
Pt will have RR=12-20
breaths/min after anxiety is
under control Q shift.

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)

Scientific Rationale (reason your nursing actions will


prevent, solve, or lessen the stated nsg dx problem)
Changes in functional capacity with heart failure have a
direct impact on the pts quality of life. The pt may have
restricted activity over time to avoid symptoms. Therefore
it is important to ask the pt about tolerance for specific
activities, such as walking a specific distance or climbing a
flight of stairs.
Ref. Gulanick, pg.333
HR increases of more than 20 BPM, systolic BP drop of
more than 20 mm Hg, light-headedness, and fatigue signify
abnormal responses to activity. Pulse oximetry provides
information on hypoxemia with exertion. If S&S of cardiac
decompensation develop, activity should be stopped
immediately.
Ref. Gulanick, pg.333
Anxiety is present in all pts with ACS to some degree. It can
cause increase in in BP, HR, RR, and as a result fears of activity,
recurrent heart attacks, and sudden death. Your role is to identify
the cause of anxiety and assist the pt in reducing it. Answer the
pts questions with clear, simple answers. This can help in pts
willingness to participate in activities and prevent dyspnea on
exertion.
Ref. Lewis, pg.757

Portable pulse oximetry can be used to assess for oxygen


desaturation. Pulse oximetry provides information on
hypoxemia with exertion. Supplemental oxygen may help
compensate for increased oxygen demand and promote
activity.
Ref. Gulanick, pg.333
Your role is to understand what the pt is currently experiencing

Pt will exhibit
activity tolerance.

Pt will have at least one


constructive coping strategy
after receiving emotional
support Q shift.

Outcomes

Provide emotional support


and encouragement Q shift.

Nursing Actions

Outcome 6

Intervention (Independent)

Pt will have Sodium=135145 mEq/L on DASH diet


Q meal.

Encourage DASH diet Q meal.

Outcome 7

Intervention (Independent)

Pt will allow for 30-minute


rest between activities Q2H.

Allow for rest between activities


Q2H.

Outcome 8

Intervention (Independent)

Pt will have HR=60-100


BPM when using a
commode Q2H.

Have pt use a commode Q2H.

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

Scientific Rationale (reason your nursing actions will prevent, solve, or


lessen the stated nsg dx problem)
RN or a dietitian should obtain a detailed diet history. The edema associated
with HF is often treated by dietary restriction of sodium. The DASH diet is
effective as a first-line therapy for many individuals with HTN. It is now
also widely used for the pt with HF. Fluid restrictions are not commonly
prescribed, but in moderate to severe HF and renal insufficiency, fluids are
limited to 2L/day. This will reduce the heart overload and promote activity
tolerance.
Ref. Lewis, pg.777-778
Allowing for periods of rest before and after planned exertion periods such as
meals, baths, treatments, and physical activity helps lower arterial pressure and
reduce the workload of the myocardium. Many hard-driving persons need the
permission to not feel lazy. Sometimes the pt may need to stop an activity that
he/she enjoys. In such situations, help the pt explore alternative activities that cause
less physical stress. This will help to avoid overexertion and promote gradual
increase of activities.
Ref. Lewis, pg.782

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

Dependent actions (MD order)

Pt will have O2 sats >90%


on O2 therapy as per MDs
order.

Administer Oxygen at 2-6 L/min


NC as per MDs order.

Outcome 10

Dependent actions (MD order)

Pt will pain level <5 (0-10)


after taking Acetaminophen
as per MDs order.

Administer Acetaminophen tab


2x325mg=625g dose, PO Q4H
PRN for mild pain as per MDs
order.

Outcomes

Nursing Actions

Outcome 12
Pt will have pain level <5
(0-10) after taking
Morphine as per MDs
order.

Dependent actions (MD 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

Dependent actions (MD order)

Pt will have no chest pain


after taking Nitroglycerin as
per MDs order.

Administer Nitroglycerine 2% UD
ointment TD Q6H 1 inch as per
MDs order.

Administer Morphine 1 mg/0.5ml


syringe IVP QH PRN for moderate
pain as per MDs order.

Use assistive devices Q ambulation.

Dependent actions (MD 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

Referrals (no outcome)

1. Refer to physical therapy before


D/C.

Teaching Outcome 15
Pt will verbalize
understanding of teaching
of a slow progression of
activity Q shift.

1. Teach a slow progression of


activity Q shift.

Teaching Outcome 16
Pt will demonstrate
understanding of signs of
overexertion Q shift.

2. Teach to recognize signs of


overexertion Q shift.

Referring a patient to Physical Therapy department can help increase


activity levels and strength. Specialized therapy may be necessary when
initially increasing activity. A structured program of low-intensity exercise
can improve functional capacity, increase self-confidence to exert self,
improve quality of life, and provide an environment for early triage of
symptoms.
Ref. Gulanick, pg.334
Appropriate progression prevents overexerting the heart while attaining
short-range goals. Duration and frequency should be increased before
intensity. E.g., walking in a room, walking short distances around the house,
and then progressively increasing distances outside of the house, saving
energy for the return trip.
Ref. Gulanick, pg. 334
Knowledge promotes awareness of when to reduce activity and provides
data for activity progression. Energy conservation techniques, such as sitting
to do tasks, sitting rather than pulling, sliding rather than lifting, organizing a
work-rest-work schedule, will reduce oxygen consumption. This will allow
for more prolonged activity.
Ref. Gulanick, pg. 334

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