Decreased Cardiac Output The heat fails to pump enough blood to meet the metabolic needs of the body.

The blood flow that supplies the heart is also decreased thus decrease in cardiac output occurs, blood then is insufficient and making it difficult to circulate the blood to all parts of the body thus may cause altered heart rate and rhythm, weakness and paleness NDx: Decreased cardiac output r/t altered heart rate and rhythm AEB bradycardia Assessment Subjective: (none)Objectives:The patient manifested the following:

Planning Nursing Interventions Short 1. Assess for Term:After 3abnormal 4 hours of heart and lung nursing sounds. interventions, 2. Monitor blood the patient pressure and with pale pulse. conjunctiva, will 3. Assess mental nail beds and participate in status and buccal mucosa activities that reduce the level of irregular workload of consciousness. rhythm of the 4. Assess pulse heart.Long patients skin bradycardic temperature pulse rate of 34 Term:After 23 days of and peripheral beats/min nursing pulses. generalized interventions, 5. Monitor weakness the patient results of will be able to laboratory and display diagnostic hemodynamic tests. stability. 6. Monitor oxygen saturation and ABGs. 7. Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs. 8. Implement strategies to treat fluid and electrolyte

Rationale Evaluation 1. Allows Short detection of Term:After left-sided nursing heart failure interventions, that may the patient occur with shall have chronic renal participated in failure activities that patients due reduce the to fluid workload of volume the excess as the heart.Long diseased Term:After 2kidneys are 3 days of unable to nursing excrete water. interventions, 2. Patients with the patient renal failure shall have are most been able to often display hypertensive, hemodynamic which is sta attributable to excess fluid and the initiation of the renninangiotensin mechanism. 3. The accumulation of waste products in the bloodstream impairs

imbalances. 9. Administer cardiac glycoside agents, as ordered, for signs of left sided failure, and monitor for toxicity. 10. Encourage periods of rest and assist with all activities. 11. Assist the patient in assuming a high Fowlers position. 12. Teach patient the pathophysiolo gy of disease, medications 13. Reposition patient every 2 hours 14. Instruct patient to get adequate bed rest and sleep 15. Instruct the SO not to leave the client unattended

oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness . 4. Decreased perfusion and oxygenation of tissues secondary to anemia and pump ineffectivenes s may lead to decreased in temperature and peripheral pulses that are diminished and difficult to palpate. 5. Results of the test provide clues to the status of the disease and response to treatments. 6. Provides information regarding the hearts ability to perfuse distal tissues with oxygenated blood

7. Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance. 8. Decreases the risk for development of cardiac output due to imbalances. 9. Digitalis has a positive isotropic effect on the myocardium that strengthens contractility, thus improving cardiac output. 10. Reduces cardiac workload and minimizes myocardial oxygen consumption. 11. Allows for better chest expansion, thereby improving pulmonary capacity. 12. Provides the patient with needed

information for management of disease and for compliance. 13. To prevent occurrence of bed sores 14. To promote relaxation to the body 15. To ensure safety and reduce risk for falls that may lead to injury

Excess Fluid Volume When blood flow through the renal artery is decreased, the baroreceptor reflex is stimulated and rennin is released into the bloodstream. Renin interacts with angiotensinogen to produce angiotensin I. When angiotensin I contacts ACE, it is converted to angiotensin II, a potent vasoconstrictor. Angiotensin II increases arterial vasoconstriction, promote release of norepinephrine from sympathetic nerve endings, and stimulates the adrenal medulla to secrete aldosterone, which enhances sodium and water absorption. Stimulation of the rennin-angiotensin system causes plasma volume to expand and preload to increase. NDx: Excessive Fluid volume r/t decreased cardiac output and sodium and water retention AEB crackles on both lung field and edema on extremities secondary to CHF and IHD Assessment Planning Subjective:(none)Objective:P Short atient manifested: Term:After 3-4 hours Edema on extremities of intervention DOB s, the Crackles heard on patient will both lung fields verbalize understandi Patient may manifest: ng of causative Change in mental Interventions 1. Establish rapport 2. Monitor and record VS 3. Assess patients general condition 4. Monitor I&O every 4 hours 5. Weigh patient daily and Rationale 1. To gain patients trust and cooperatio n 2. To obtain baseline data 3. To determine what Evaluation Short Term:Pt shall have verbalized understandi ng of causative factors and demonstrat e behaviors to resolve

status (lethargy or confusion) Restlessness and anxiety

factors and demonstrat e behaviors to resolve excess fluid volume.Lo ng Term:After 3-4 days of nursing intervention s, the patient will demonstrat e adequate fluid balanced AEB output equal to exceeding intake, clearing breath sounds, and decreasing edema.

compare to previous weights. 6. Auscultate breath sounds q 2hr and pm for the presence of crackles and monitor for frothy sputum production 7. Assess for presence of peripheral edema. Do not elevate legs if the client is dyspneic. 8. Follow lowsodium diet and/or fluid restriction 9. Encourage or provide oral care q2 10. Obtain patient history to ascertain the probable cause of the fluid disturbance. 11. Monitor for distended neck veins and ascites 12. Evaluate urine output in response to diuretic therapy. 13. Assess the need for an indwelling urinary catheter. 14. Institute/instruc

approach excess fluid to use in volume.Lo treatment ng Term:Pt 4. I&O shall have balance demonstrat reflects ed adequate fluid fluid status balance 5. Body AEB output weight is a equal to sensitive exceeding indicator intake, of fluid clearing balance breath and an sounds and increase decreasing indicates ed fluid volume excess. 6. When increased pulmonary capillary hydrostati c pressure exceeds oncotic pressure, fluid moves within the alveolar septum and is evidenced by the auscultatio n of crackles. Frothy, pinktinged sputum is an indicator

t patient regarding fluid restrictions as appropriate.

that the client is developin g pulmonary edema 7. Decreased systemic blood pressure to stimulatio n of aldosteron e, which causes increased renal tubular absorption of sodium Lowsodium diet helps prevent increased sodium retention, which decreases water retention. Fluid restriction may be used to decrease fluid intake, hence decreasing fluid volume excess. 8. The client senses thirst

because the body senses dehydratio n. Oral care can alleviate the sensation without an increase in fluid intake. 9. Heart failure causes venous congestion , resulting in increased capillary pressure. When hydrostatis pressure exceeds interstitial pressure, fluids leak out of ht ecpaillarie s and present as edema in the legs, and sacrum. Elevation of legs increases venous return to the heart. 10. May include

increased fluids or sodium intake, or compromi sed regulatory mechanis ms. 11. Inidicates fluid overload 12. Focus is on monitorin g the response to the diuretics, rather than the actual amount voided 13. Treatment focuses on diuresis of excess fluid. 14. This helps reduce extracellul ar volume.

Acute Pain In ischemic heart disease, atherosclerosis develops in the coronary arteries, causing them to become narrowed or blocked. When a coronary artery is blocked, blood flow to the area of the heart supplied by that artery is reduced. If the remaining blood flow is inadequate to meet the oxygen demands of the heart, the area may become ischemic and injured and myocardial infarction may result. Neural pain receptors are stimulated by local mechanical stress resulting from abnormal myocardial contraction. Assessment Planning Subjective:PainObjective:Pat Short Interventions 1. Assess Rationale 1. To identify Evaluation Short

ient manifested:

Term:After 3-4 hours of nursing (+) DOB with a rate of 7 out of intervention s, the 10 patients with complaints of pain will chest pain decrease unprovoked from 7 to 3 as Patient may manifest: verbalized by the Restlessness patient.Lon g Term:After 2-3 days of nursing intervention s, the patient will demonstrate activities and behaviors that will prevent the recurrence of pain.

2.

3.

4.

5.

6. 7.

8.

patient pain for intensity using a pain rating scale, for location and for precipitating factors. Administer or assist with selfadministrati on of vasodilators, as ordered. Assess the response to medications every 5 minutes Provide comfort measures. Establish a quiet environment . Elevate head of bed. Monitor vital signs, especially pulse and blood pressure, every 5 minutes until pain subsides. Teach patient relaxation techniques and how to use them to reduce

2.

3.

4.

5.

6.

intensity, Term:Patie precipitating nt shall factors and have location to verbalized assist in a decrease accurate in pain diagnosis. from a The scale of 7 vasodilator to 3.Long nitroglycerin Term:The enhances patient blood flow to shall have the demonstrat myocardium. ed activities It reduces the and amount of behaviors blood that will returning to prevent the the heart, recurrence decreasing of pain. preload which in turn decreases the workload of the heart. Assessing response determines effectiveness of medication and whether further interventions are required. To provide nonpharmaco logical pain management. A quiet environment reduces the energy demands on the patient. Elevation improves

stress. 9. Teach the patient how to distinguish between angina pain and signs and symptoms of myocardial infarction.

chest expansion and oxygenation. 7. Tachycardia and elevated blood pressure usually occur with angina and reflect compensatory mechanisms secondary to sympathetic nervous system stimulation. 8. Anginal pain is often precipitated by emotional stress that can be relieved nonpharmacologi cal measures such as relaxation. 9. In some case , the chest pain may be more serious than stable angina. The patient needs to understand the differences in order to seek emergency care in a timely fashion.

Activity Intolerance As heart failure becomes more severe, the heart is unable to pump the amount of blood required to meet all of the bodys needs. To compensate, blood is diverted away from less-crucial areas, including the arms and legs, to supply the heart and brain. As a result, people with heart failure often feel weak (especially in their arms and legs), tired and have difficulty performing ordinary activities such as walking, climbing stairs or carrying groceries NDx: Activity intolerance r/t imbalance O2 supply and demand AEB limited ROM, generalized weakness and DOB Assessment Planning Subjective:Objective:Patient Short manifested: Term:After 3-4 hours of nursing interventions, generalized the patient will weakness use identified limited range of motion as observed techniques to abnormal pulse rate improve activity and rhythm intoleranceLong (+) DOB Term:After 2-3 days of nursing interventions, the patient will report measurable increase in activity intolerance.. Interventions 1. Establish Rapport 2. Monitor and record Vital Signs 3. Assess patients general condition 4. Adjust clients daily activities and reduce intensity of level. Discontinue activities that cause undesired psychological changes 5. Instruct client in unfamiliar activities and in alternate ways of conserve energy 6. Encourage patient to have adequate bed rest and sleep 7. Provide the Rationale Evaluation 1. To gain clients participati on and cooperatio n in the nurse patient interaction 2. To obtain baseline data 3. To note for any abnormali ties and deformitie s present within the body 4. To prevent strain and overexerti on 5. To conserve energy and promote safety 6. to relax the body 7. to provide

patient with a calm and quiet environment 8. Assist the client in ambulation 9. Note presence of factors that could contribute to fatigue 10. Ascertain clients ability to stand and move about and degree of assistance needed or use of equipment 11. Give client information that provides evidence of daily or weekly progress 12. Encourage the client to maintain a positive attitude 13. Assist the client in a semi-fowlers position 14. Elevate the head of the bed 15. Assist the client in learning and demonstrating appropriate safety measures

relaxation 8. to prevent risk for falls that could lead to injury 9. fatigue affects both the clients actual and perceived ability to participate in activities 10. to determine current status and needs associated with participati on in needed or desired activities 11. to sustain motivatio n of client 12. to enhance sense of well being 13. to promote easy breathing 14. to maintain an open airway 15. to prevent injuries 16. to avoid

16. Instruct the SO not to leave the client unattended 17. Provide client with a positive atmosphere 18. Instruct the SO to monitor response of patient to an activity and recognize the signs and symptoms

risk for falls 17. to help minimize frustration and rechannel energy 18. to indicate need to alter activity lev

Ineffective Airway Clearance Mucus is produced at all times by the membranes lining the air passages. When the membranes are irritated or inflamed, excess mucus is produced and it will retain in tracheobronchial tree. The inflammation and increased in secretions block the airways making it difficult for the person to maintain a patent airway. In order to expel excessive secretions, cough reflex will be stimulated. An increased in RR will also be expected as a compensatory mechanism of the body due to obstructed airways. NDx: Ineffective airway clearance RT retained secretions AEB presence of rales on both lung fields. Assessment Planning Subjective:Objective:Patie Short nt manifested: Term:After 3-4 hours of nursing with productive cough yellowish in interventions , the patient color will be able presence of rales upon auscultation to establish and maintain (+) DOB airway with pale patency conjunctiva, nail AEB beds and buccal absence of Interventions 1. Monitor and record vital signs. 2. Assess patients condition. 3. Monitor respirations and breath sounds, noting rate and sounds. 4. Position head Rationale Evaluation 1. To obtain Short baseline Term:The data patient shall 2. To know have been the patients able to general establish and condition maintain 3. To airway determine patency respiratory AEB distress and absence of accumulatio respiratory n of distress.Lon

mucosa

signs of respiratory distress.Lon g Term:After 2-3 days of NI, the patient will be able to demonstrate improve airway clearance AEB reduction of congestion with breath sounds clear and improved RR.

properly 5. Position appropriately and discourage use of oilbased products around nose. 6. Auscultate breath sounds and assess air movement. 7. Encourage deep breathing and coughing exercises 8. Elevate head of bed and encourage frequent position changes. 9. Keep back dry and loosen clothing 10. Observed for signs and symptoms of infection. 11. Instruct patient have adequate rest periods and limit activities to level of activity intolerance. 12. Give expectorants and bronchodilato rs as ordered. 13. Suction

secretions. g Term:The 4. To open or patient shall maintain have been open able to airway. demonstrate 5. To prevent improve vomiting airway with clearance aspiration AEB into lungs. reduction of 6. To ascertain congestion status and with breath note sounds clear progress. and 7. To improved maxixmize RR. effort 8. To promote maximal inspiration, enhance expectoratio n of secretions in order to improve ventilation 9. To promote comfort and adequate ventilation 10. To identify infectious process and promote timely intervention . 11. Rest will prevent fatigue and decrease oxygen demands for metabolic demands

secretions PRN 14. Administer oxygen therapy and other medications as ordered.

12. To further mobilize secretions 13. To clear airway when secretions are blocking the airway 14. Indicated to increase oxygen saturation.