Care Plan Exercise

1. Care Plan Exercise Cristi Day RN, MSN, FNP-C Texas A&M University – Corpus Christi

2. Ineffective Tissue Perfusion: Cardiopulmonary • Definition: Decrease in oxygen resulting in failure to nourish tissues at capillary level • Defining Characteristics (AEB): use of accessory muscles, capillary refill longer than 3 seconds, abnormal ABGs, chest pain, sense of impending doom, bronchospasm, dyspnea, dysrhythmias, nasal flaring, chest retraction.

3. Ineffective Tissue Perfusion: Cardiopulmonary Cont’d • Related Factors (R/T): Hypovolemia, interruption of arterial flow, hypervolemia, exchange problems, interruption of venous flow, mechanical reduction of venous and/or arterial blood flow, hypoventilation, impaired transport of oxygen across alveolar and/or capillary membrane, mismatch of ventilation with blood flow, decreased hemoglobin concentration in blood, enzyme poisoning, altered affinity of hemoglobin of oxygen

4. Ineffective Tissue Perfusion Nursing Diagnosis Statement Ineffective Tissue Perfusion: cardiopulmonary R/T interruption of aterial flow AEB altered RR, CP, sense of impending doom, dyspnea

5. Ineffective Tissue Perfusion: Care Map Ineffective Tissue Perfusion: cardiopulmonary R/T interruption of aterial flow AEB altered RR, CP, sense of impending doom, dyspnea CP 8/10 Fees like he going to die RR 24 SOB

6. Ineffective Tissue Perfusion: Outcome Goals • Client will demonstrate adequate tissue perfusion as evidenced by: skin warm & dry, absence of dyspnea, absence of chest pain, absence of feelings of impending doom within 2 hours of admission. • Client will verbalize knowledge of treatment regimen including lifestyle modifications, medical nutrition therapy, and medication regimen actions and possible side effects before discharge from acute care.

7. Ineffective Tissue Perfusion: Care Map Ineffective Tissue Perfusion: cardiopulmonary R/T interruption of aterial flow AEB altered RR, CP, sense of impending doom, dyspnea CP 8/10 Fees like he going to die RR 24 SOB Client will demonstrate adequate tissue perfusion as evidenced by: skin warm & dry, absence of dyspnea, absence of chest pain, & absence of feelings of impending doom within 2 hours of admission. Client will verbalize knowledge of treatment regimen including lifestyle modifications, medical nutrition therapy, and medication regimen actions and possible side effects before discharge from acute care.

8. Ineffective Tissue Perfusion: Interventions Teach client/family about medications, their regimen, actions, and side effects. RA: Appropriate instruction increases accuracy & safety of medication administration. (A&L p 904) Assess for signs of decreased tissue perfusion: CP, clammy skin, dyspnea, feelings of impending doom. RA: Indicative of inadequate blood supply to myocardium (A&L p269) Teach client/family importance and methods of lifestyle modification and dietary modifications for smoking cessation, hyperlipidemia control, HTN control. RA: All these risk factors for atherosclerosis can be modified. (A&L p 1237) Administer nitroglycerin SL and oxygen as ordered. RA: This improves myocardial perfusion (http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=55 Anticipate need for possible embolectomy, heparinization, vasodilator therapy, thrombolytic therapy, and fluid rescue. RA: These facilitate perfusion when obstruction to blood flow exists or when perfusion has dropped to such a danger level that ischemic damage would be inevitable without treatment. http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=55

9. Ineffective Tissue Perfusion: Care Map Ineffective Tissue Perfusion: cardiopulmonary R/T interruption of aterial flow AEB altered RR, CP, sense of impending doom, dyspnea CP 8/10 Fees like hes going to die RR 24 Client will demonstrate adequate tissue perfusion as evidenced by: skin warm & dry, absence of dyspnea, absence of chest pain, & absence of feelings of impending doom within 2 hours of admission. Client will verbalize knowledge of treatment regimen including lifestyle modifications, medical nutrition therapy, and medication regimen actions and possible side effects before discharge from acute care. SOB Assess for signs of decreased tissue perfusion: CP, clammy skin, dyspnea, feelings of impending doom. RA: Indicative of inadequate blood supply to myocardium (A&L p269) Administer nitroglycerin SL and oxygen as ordered. RA: This improves myocardial perfusion (http://www1.us.elsevierhealth.com) Teach client/family about medications, their regimen, actions, and side effects. RA: Appropriate instruction increases accuracy & safety of medication administration. (A&L p 904) Anticipate need for possible embolectomy, heparinization, vasodilator therapy, thrombolytic therapy, and fluid rescue. RA: These facilitate perfusion when obstruction to blood flow exists or when perfusion has dropped to such a danger level that ischemic damage would be inevitable without treatment. http://www1.us.elsevierhealth.com Teach client/family importance and methods of lifestyle modification and dietary modifications for smoking cessation, hyperlipidemia control, HTN control. RA: All these risk factors for atheroslerosis can be modified. (A&L p 1237)

10. Ineffective Tissue Perfusion: Evaluation Client will demonstrate adequate tissue perfusion as evidenced by: skin warm & dry, absence of dyspnea, absence of chest pain, & absence of feelings of impending doom within 2 hours of admission. 1. Goal Partially Met. Client skin warm and dry, no c/o dyspnea, chest pain resolved, and feelings of impending doom resolved within 8 hours of admission. 2. Client will verbalize knowledge of treatment regimen including lifestyle modifications, medical nutrition therapy, and medication regimen actions and possible side effects before discharge from acute care. 2. Goal Met. Client verbalizes understanding of activity and dietary changes needed to modify risks for CAD and verbalizes understanding of medications, their actions and side effects prior to discharge to home.

11. Activity Intolerance • Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities. • Defining Characteristics (AEB): Verbal report of fatigue or weakness, abnormal heart rate or blood pressure response to activity, exertional discomfort or dyspnea, electrocardiographic changes reflecting arrhythmias or ischemia.

12. Activity Intolerance - Cont’d • Related Factors (R/T): Bed rest or immobility, generalized weakness, sedentary lifestyle, imbalance between oxygen supply and demand.

13. Activity Intolerance – Nursing Diagnosis Statement Activity Intolerance R/T imbalance between oxygen supply and demand (CHF decreased Cardiac Output) AEB fatigue, exertional dyspnea.

14. Activity Intolerance : Care Map Activity Intolerance R/T imbalance between oxygen supply and demand (CHF decreased Cardiac Output) AEB fatigue, exertional dyspnea. Exertional dyspnea c/o fatigue

15. Activity Intolerance : Outcome Goals • Client will demonstrate increased activity intolerance (decrease report of fatigue and decreased exertional dyspnea by time of discharge. • Client will verbalize an understanding of the need to gradually increase activity based on testing, tolerance, and symptoms by end of second day of admission.

16. Activity Intolerance : Interventions Consider us of the 6-minute walk test to determine physical ability. RA: The 6-minute walk test was shown to be highly reproducible in determining ability to ambulate in a client in Heart Failure. (A&L p 152) Provide emotional support and encouragement to the client to gradually increase activity. RA: Fear of breathlessness, pain, or falling may decrase willingness to increase activity. (A&L 151) Refer to cardiac rehab program for education, evaluation, and support to increase activity and rebuild life. RA: Exercise can help many client with heart failure. A carefully monitored exercise program can improve both exercise capacity and quality of life in mild to moderate heart failure clients (A&L 152) Allow for periods of rest before and after planned exertion periods. RA: Limited exercise toleratnce in heart failure is often the first and central clinical feature, reflecting both decreased cardiac and peripheral responses. (A&L 152) Help client to set up an activity log to record exercise and exercise tolerance. RA: Will help client to understand his level of activity tolerance. (A&L 155)

17. Activity Intolerance : Care Map Client will demonstrate increased activity intolerance (decrease report of fatigue and decreased exertional dyspnea by time of discharge. Client will verbalize an understanding of the need to gradually increase activity based on testing, tolerance, and symptoms by end of second day of admission. Exertional dyspnea c/o fatigue Activity Intolerance R/T imbalance between oxygen supply and demand (CHF decreased Cardiac Output) AEB fatigue, exertional dyspnea. Consider us of the 6-minute walk test to determine physical ability. RA: The 6-minute walk test was shown to be highly reproducible in determining ability to ambulate in a client in Heart Failure. (A&L p 152) Allow for periods of rest before and after planned exertion periods.RA: Limited exercise tolerance in heart failure is often the first and central clinical feature, reflecting both decreased cardiac and peripheral responses. (A&L 152) Help client to set up an activity log to record exercise and exercise tolerance. RA: Will help client to understand his level of activity tolerance. (A&L 155) Refer to cardiac rehab program for education, evaluation, and support to increase activity and rebuild life. RA: Exercise can help many client with heart failure. A carefully monitored exercise program can improve both exercise capacity and quality of life in mild to moderate heart failure clients (A&L 152) Provide emotional support and encouragement to the client to gradually increase activity. RA: Fear of breathlessness, pain, or falling may decrase willingness to increase activity. (A&L 151)

18. Activity Intolerance : Evaluation Client will demonstrate increased activity intolerance (decrease report of fatigue and decreased exertional dyspnea by time of discharge. Client will verbalize an understanding of the need to gradually increase activity based on testing, tolerance, and symptoms by end of second day of admission. 1. Goal met. Client demonstrated increased activity intolerance. Able to walk 150 ft without significant dyspnea and without report of fatigue by discharge home (4 days). 2. Goal met. Client was able to identify activity tolerance and symptoms of intolerance and verbalized understanding of the need to gradually increase his activity by the 2nd day of admission.

19. CARE PLAN EVALUATION FORM Problem List: High Risk Actual Problems identified come from assessment data All problems are noted that assessment data shows/ Priorities identified. 10 Nursing Diagnostic Statement: Stated in nursing terms (NANDA format) “Related to” is pathophysiologically based Supported by Objective Data Supported by Subjective Data 10 Goals and Outcomes: Relate to Problem Long and Short Term Goal, States desired patient outcome criteria Realistic time frame Measurable 10 Carative Factors/Interventions: Contain what, how much, where, when Related to goals and outcomes Could be completed by another nurse for the client 10 Rationale: Based on Valid Theory; States what the nursing action modifies within the body to accomplish the desired outcome Refers to interventions, References (page and source) 10 Evaluation: States how goal was met or not met Recommended changes Based on outcome criteria 10