Professional Documents
Culture Documents
Acute Pain
May be related to
Possibly evidenced by
Narrowed focus
Desired Outcomes
Nursing Interventions
Rationale
Pain and decreased cardiac output may
stimulate the sympathetic nervous system
to release excessive amounts of
norepinephrine, which increases platelet
medication.
Nursing Interventions
Rationale
indicate need for change in therapeutic
regimen.
of pain.
unstable angina.
Decreased cardiac output (which may
occur during ischemic myocardial episode)
side).
anginal episodes.
breath.
or appears anxious.
Nursing Interventions
Rationale
escalate and/or prolong ischemic pain.
Presence of nurse can reduce feelings of
fear and helplessness.
myocardial workload.
spray.
Nursing Interventions
Rationale
(Inderal)
severe conditions.
2. Knowledge Deficit
May be related to
Lack of exposure
Inaccurate/misinterpretation of information
Possibly evidenced by
Desired Outcomes
Assume responsibility for own learning, looking for information and asking
questions.
Nursing Interventions
Rationale
Patients with angina need to learn why it
Nursing Interventions
Rationale
attacks.
avoided.
Knowledge of the significance of risk
Review importance of weight control,
cessation of smoking, dietary changes,
and exercise.
exhaustion.
consultation, as indicated.
rest periods.
threshold.
do if attack occurs.
techniques).
Review prescribed medications for
Nursing Interventions
Rationale
often requires the use of many drugs
appointments.
3. Anxiety
May be related to
Situational crises
Threat to or change in health status (disease course that can lead to further
compromise, debility, even death)
Negative self-talk
Possibly evidenced by
Increased tension/helplessness
Desired Outcomes
Nursing Interventions
Rationale
stress testing.
patient as before.
Nursing Interventions
Tell patient the medical regimen has been
designed to limit future attacks and
increase cardiac stability.
Rationale
Encourages patient to test symptom
control, to increase confidence in medical
program, and to integrate abilities into
perceptions of self.
May be desired to help patient relax until
physically able to reestablish adequate
coping strategies.
May be relate to
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Rationale
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per 24 hours) may indicate acute failure,
especially in high-risk patients. Accurate
monitoring of I&O is necessary for
determining renal function and fluid
replacement needs and reducing risk of
fluid overload. Do note that hypervolemia
usually occurs in anuric phase of ARF and
may mask the symptoms.
Measures the kidneys ability to
concentrate urine. In intrarenal failure,
Nursing Interventions
Rationale
changes in the renin-angiotensin system.
Invasive monitoring may be needed for
assessing intravascular volume, especially
in patients with poor cardiac function.
Fluid overload may lead to pulmonary
restlessness.
developing hypoxia.
Nursing Interventions
Rationale
indicate fluid overload or metabolic
acidosis.
In ATN, tubular functional integrity is lost
and sodium resorption is impaired,
Serum sodium.
Serum potassium.
Hb/Hct.
Nursing Interventions
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replace output from all sources plus
estimated insensible losses (metabolism,
diaphoresis). Prerenal failure (azotemia) is
treated with volume replacement and/or
vasopressors. The oliguric patient with
indicated.
Prostaglandins.
Nursing Interventions
Rationale
agents from nephrons.
Catheterization excludes lower tract
obstruction and provides means of
(CRRT).
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Rationale
Fluid volume excess, combined with
hypertension (common in renal failure)
rhythm.
Nursing Interventions
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acute dialysis.
Pallor may reflect vasoconstriction or
consciousness.
twitching, hyperreflexia.
and function.
Nursing Interventions
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desired activities.
workload.
Calcium.
Magnesium.
Nursing Interventions
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therapeutic effect without toxicity.
Serum calcium is often low but usually
does not require specific treatment in ARF.
Calcium gluconate
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Rationale
Aids in identifying deficiencies and dietary
needs. General physical condition, uremic
menu choices.
Nursing Interventions
Rationale
cracked. Mouth care soothes, lubricates,
and helps freshen mouth taste, which is
Weigh daily.
potassium.
effectiveness of therapy.
Determines individual calorie and nutrient
needs within the restrictions, and identifies
Nursing Interventions
Rationale
Medications and decrease in GFR can
cause electrolyte imbalances and may
further cause renal injury.
Restriction of these electrolytes may be
Calcium carbonate
Vitamin D
Antiemetics: prochlorperazine
intake.
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Promote good hand washing by patient
and staff.
Rationale
ascending UTI.
Nursing Interventions
Rationale
infections.
with differential.
Excessive loss of fluid (diuretic phase of ARF, with rising urinary volume and
delayed return of tubular reabsorption capabilities)
Possibly evidenced by
Desired Outcomes
Display I&O near balance; good skin turgor, moist mucous membranes,
palpable peripheral pulses, stable weight and vital signs, electrolytes within
normal range.
Nursing Interventions
Rationale
Assessment can help estimate fluid
replacement needs. Fluid intake should
period.
HR.
suggest hypovolemia.
In diuretic or postobstructive phase of
renal failure, urine output can exceed 3
L/day. Extracellular fluid volume depletion
Nursing Interventions
Rationale
6. Deficient Knowledge
May be related to
Lack of exposure/recall
Information misinterpretation
Possibly evidenced by
Complications
Desired Outcomes
Nursing Interventions
Rationale
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and family.
Nursing Interventions
Rationale
Decreased metabolic energy production,
presence of anemia, and states of
discomfort commonly result in fatigue.
laboratory studies.
altered mentation.
2. Activity Intolerance
Nursing Diagnosis
Activity intolerance
May be related to
Possibly evidenced by
Development of dysrhythmias
Exertional angina
Generalized weakness
Desired Outcomes
Nursing Interventions
Rationale
Trends determine patients response to
defecation).
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Rationale
Cerebral perfusion is directly related to
cardiac output and is also influenced by
electrolyte and/or acid-base variations,
hypoxia, and systemic emboli.
Systemic vasoconstriction resulting from
diminished cardiac output may be
evidenced by decreased skin perfusion and
diminished pulses.
breathing.
Nursing Interventions
Rationale
however, sudden or continued dyspnea
may indicate thromboembolic pulmonary
complications.
Decreased intake or persistent nausea
Nursing Interventions
Rationale
antacids;
(Abbokinase);
Nursing Interventions
Rationale
before they become totally blocked. The
mechanism includes a combination of
vessel stretching and plaque compression.
Intracoronary stents may be placed at the
May be related to
Possibly evidenced by
Changes in BP (hypotension/hypertension)
Chest pain
Desired Outcomes
Nursing Interventions
Rationale
Tachycardia is usually present (even at
rest) to compensate for decreased
ventricular contractility. Premature atrial
contractions (PACs), paroxysmal atrial
telemetry is available.
Monitor BP.
Nursing Interventions
Rationale
able to compensate, and profound
hypotension may occur.
Pallor is indicative of diminished peripheral
perfusion secondary to inadequate cardiac
indicated.
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Rationale
formation.
pallor of extremity.
thrombophlebitis.
Incidence of toxicity is high (20%)
indicated.
(Apresoline); combination
Nursing Interventions
Rationale
workload. Note: Parenteral vasodilators
(Nitropress) are reserved for patients with
severe HF or those unable to take oral
medications.
Angiotensin II receptor
antagonists: eprosartan (Teveten),
irbesartan (Avapro), valsartan (Diovan);
Digoxin (Lanoxin)
Beta-adrenergic receptor
Nursing Interventions
Rationale
Decreases vascular resistance and venous
return, reducing myocardial workload,
Morphine sulfate.
(Coumadin).
Nursing Interventions
Rationale
measured noninvasively by using thoracic
electrical bioimpedance (TEB) technique.
Useful in determining effectiveness of
therapeutic interventions and response to
activity.
studies.
therapy.
May be necessary to correct
Cardiomyoplasty.
Cardiomyoplasty, an experimental
procedure in which the latissimus dorsi
muscle is wrapped around the heart and
electrically stimulated to contract with
Nursing Interventions
Rationale
each heartbeat, may be done to augment
ventricular function while the patient is
awaiting cardiac transplantation or when
transplantation is not an option.
Other new surgical techniques include
transmyocardial revascularization
(percutaneous [PTMR]) using CO2 laser
Transmyocardial revascularization.
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Auscultate breath sounds, noting crackles,
wheezes.
Rationale
Reveals presence of pulmonary congestion
and collection of secretions, indicating
need for further intervention.
deep breathing.
delivery.
pillows.
Place patient in Fowlers position and give
supplemental oxygen.
Nursing Interventions
Rationale
indicated.
Bronchodilators: aminophylline
Prolonged bedrest
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Rationale
or blanched areas.
Nursing Interventions
Rationale
compromised area may cause tissue
injury.
develop ketoacidosis, but most adults with this type experience only modest
fasting hyperglycemia unless they develop and infection as another stressor.
Patients with type 1 idiopathic diabetes are prone to ketoacidosis.
Other specific types category includes people who have diabetes as a result
of a genetic defect, endocrinopathies or exposure to certain drugs or
chemicals.
Statistics
Diabetes affects 18% of people over the age of 65, and approximately 625,000 new
cases of diabetes are diagnosed annually in the general population. Conditions or
situations known to exacerbate glucose/insulin imbalance include (1) previously
undiagnosed or newly diagnosed type 1 diabetes; (2) food intake in excess of available
insulin; (3) adolescence and puberty; (4) exercise in uncontrolled diabetes; and (5)
stress associated with illness, infection, trauma, or emotional distress. Type 1 diabetes
can be complicated by instability and diabetic ketoacidosis (DKA). DKA is a lifethreatening emergency caused by a relative or absolute deficiency of insulin.
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Glucagon: Elevated level is associated with conditions that produce (1) actual
hypoglycemia, (2) relative lack of glucose (e.g., trauma, infection), or (3) lack
of insulin. Therefore, glucagon may be elevated with severe DKA despite
hyperglycemia.
Electrolytes:
Urine: Positive for glucose and ketones; specific gravity and osmolality may
be elevated.
Desired Outcomes
infection.
Nursing Interventions
Rationale
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cranberry juice can help prevent
bacteria from adhering to the bladder
wall, reducing the risk of recurrent UTI.
Desired Outcomes
Nursing Interventions
Rationale
3. Powerlessness
Nursing Diagnosis
Powerlessness
May be related to
Dependence on others
Possibly evidenced by
Desired Outcomes
Assist in planning own care and independently take responsibility for self-care
activities.
Nursing Interventions
Rationale
Nursing Interventions
Rationale
control wants to be cared for by others
and may project blame for
circumstances onto external factors.
May be related to
Possibly evidenced by
Diarrhea
Desired Outcomes
laboratory values.
Nursing Interventions
Rationale
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May be related to
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Rationale
Acetone breath is due to breakdown of
acetoacetic acid and should diminish as
ketosis is corrected. Correction of
hyperglycemia and acidosis will cause
the respiratory rate and pattern to
approach normal.
Weigh daily.
Nursing Interventions
Rationale
predispose patient to aspiration.
6. Fatigue
Nursing Diagnosis
Fatigue
May be related to
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Rationale