nursing care plans

Heart failure is the inability of the heart to supply blood to meet physiological demands without using compensatory changes. The blood is backed up in the pulmonary vasculature, and when the pulmonary capillary pressure is exceeded by the oncotic pressure of the proteins in the plasma fluid (usually > 30 mmHg), the fluid leaks into the interstitial spaces.

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NURSING CARE PLANS

Outcome Criteria

INTERVENTIONS RATIONALES

INTERVENTIONS RATIONALES INTERVENTIONS RATIONALES

Instruction, Information, Demonstration

Discharge or Maintenance Evaluation

Indicates disturbances of normal blood flow within the heart related to incompetent valves, septal defects, or papillary muscle/chordae tendonae complications after MI. Reduced venous return to the heart can result in low cardiac output; oliguria results from reduced venous return due to fluid retention.

Information, Instruction, Demonstration

S4 gallops may be associated with myocardial ischemia, ventricular rigidity, pulmonary hypertension, or systemic hypertension, which may reduce cardiac output. Increasing intra-abdominal pressure results in a precipitous drop in cardiac output by preventing blood from being pumped into the thoracic cavity, thus pumping less blood into the heart, which then slows the heart rate.

Outcome Criteria

INTERVENTIONS RATIONALES Outcome Criteria

Discharge or Maintenance Evaluation

Related to: bed rest, decreased tissue perfusion, edema, immobility, decreased peripheral

LEFT-SIDED HEART FAILURE

RIGHT-SIDED HEART FAILURE

MYoeardial Infaretion (MD

MEDICAL CARE

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Related to: chest pain due to decreased blood flow to the myocardium, myocardial ischemia or infarction, post-procedure discomfort, chest wall pain after surgery, pericarditis. Defining characteristics: chest pain with or without radiation, facial grimaces, clutching of hands or chest, restlessness, diaphoresis, changes in pulse and blood pressure, dyspnoea, dizziness.

Related to: damaged myocardium, decreased con- tractility, dysrhythmias, conduction defects,

Reduced venous return to the heart can result in low cardiac output; oliguria results from decreased venous return due to fluid retention. It is used in the treatment of vasoconstriction and 10 reduces heart rate and contractility, reduces blood pressure by relaxing venous and arterial smooth muscle, which then increases cardiac output and reduces cardiac workload.

INTERVENTIONS RATIONALES INTERVENTIONS MTIONALES

Related to: increased sodium and water retention, decreased organ perfusion

Blood pressure will be maintained within normal limits, and edema will be absent or minimal in all parts of the body. Fluid balance will be maintained and blood pressure will be within normal baseline limits.

Related to: change in health status, fear of death, threat to body image, threat to role functioning,

Medications may be needed to correct fluid overload depending on the emergency nature of the problem. Weight gain can be the first visible sign of fluid overload and should be monitored to prevent complications.

INTERvENTf ONS RATIONALES

Determine fluid balance by measuring intake and output, and observing decreased output and concentrated urine. Related to: change in health status, fear of death, threat to body image, threat to role functioning,.

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The patient will be able to verbalize and demonstrate understanding of the information provided regarding the condition, medications, and treatment regimen. Provides information that the patient has gained a full understanding of the instruction and is able to demonstrate the correct information.

MYOCARDZAL INFARCTION (MI)

COMPLICATIONS RESULTING FROM MI THAT MAY LEAD TO DEATH IF NOT TREATED

MEDICAL CARE

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Oxygenation will be optimal as evidenced by pulse oximetry greater than 90%, S in 0 2 greater than 75%, or normal ABG. The patient will be able to correctly verbalize information about medications, diet, and activity restrictions.

PERICARDITIS

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Endocarditis can be divided into acute and subacute classes, depending on the virulence of the organism involved and the length of duration. As these organisms grow, more platelets and fibrin adhere and eventually the valves are destroyed, the vegetations break off and embolize to other parts of the body, and a systemic immune response occurs.

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Bleeding into the subungual areas can be seen in early infective endocarditis, but can be seen in trauma, with hemo- or peritoneal dialysis or with mitral stenosis. In some cases, early negative results may indicate only that the culture could not be grown due to low levels of bacteria or an unusual organism present.

INTEKVENTIONS RATIONALES

Discharge or Maintenance Evaluation Patient will be normothermic with no overt

Related to: inhibition of antibodies due to immunological system action, inflammatory

INFECTIVE ENDOCARDITIS

Hypertension

INTERVENTIONS RATIONALES Infarmatian, Instruction, Demonstration

Related to: increased catecholamine stimulation, increased blood pressure, decreased cardiac output,

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Associated with: lack of understanding, lack of understanding of medical condition, lack of recall Defining features: questions about problems, inadequate follow-up of instructions given, misconceptions, lack of improvement from previous regimen, development of preventable complications. It provides information about the patient's understanding of the condition and a starting point for teaching.

INTERVENTIONS RA'TIBNALES Discharge or Maintenance Evaluation

HYPERTENSION

Throm bop hlebi tis

1251 Fibrinogen uptake test: a radioactive scan performed after radioactive fibrinogen is injected,

Anticoagulants: heparin, coumadin, warfarin to prolong clotting time to prevent further clot for-

Related to: impaired blood flow, venous stasis, venous obstruction

Defining characteristics: pain, tissue edema, decreased peripheral pulses, prolonged capillary

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Related to: edema, venous stasis, bed rest, surgery, pressure, altered blood circulation and circulation, altered pressure, altered blood circulation and circulation, altered metabolic states.

Defining characteristics: skin surface disruptions, incisions, ulcerations, wounds that do not heal

INTERWNTIONS RATIONALES

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It provides references for the patient and family to refer to after discharge and can improve understanding of verbal instructions. The patient will be able to verbalize an understanding of safety precautions, correct dosage and administration of all medications and activities.

THROMBOPHLEBITIS

Intra-Aortic Balloon Pump

NURSING CARE PLANS

Diastolic PA pressures reflect LVEDP and are an indirect measure of LV function with normals ranging from 10-20 mmHg. Notify M D if addition cannot be maintained, afterload does not decrease, or reddish-brown fluid is observed in IAB tube.

Related to: invasive lines, catheters, puncture wounds, invasive procedures, environmental expo-

Defining characteristics: disruption of skin sur- faces, redness, drainage, elevated temperature

Instruction, Information, Demonstration

Pacemakers

INTERVENTIONS RATIONALE

INTERVENTIONS RATIONALES INTERTENTIONS RATIONALES

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Defining features: decreased cardiac output, bleeding, diaphoresis, hypotension, restlessness, dyspnea, cyanosis, chest pain, muscle twitching, hiccups, muffled heart sounds, jugular vein distension, pulsus paradoxus. Monitor for dyspnea, chest pain, pallor, cyanosis, absent or decreased breath sounds, tracheal deviation, and sense of impending doom.

Depending on the time frame for patient education prior to the insertion of the pacemaker, the patient may not have received sufficient information, and may have difficulty coping with changes in his body appearance as well as generalized health status and loss of control. The patient will be able to solve problems and identify short and long term goals within.

Related to: lack of understanding, lack of under- standing of medical condition, lack of recall, new

May suggest problems adjusting to health condition, grief response to loss of function, or concern about others' acceptance of patient's new body status. Facilitates identification that emotions are not unusual and must be recognized in order to deal effectively with them.

PACEMAKERS

In coronary artery bypass graft (CABG) surgery, a graft from the arms or legs is anastomosed to the aorta with the distal part of the involved coronary artery to bypass the diseased obstruction and ensure proper blood flow to the heart. A cannula is placed in a vein and an artery and then attached to the cardiopulmonary bypass machine where the diverted blood is mechanically oxygenated and circulated to other parts of the body.

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It may indicate cardiac tamponade in a heart that cannot fill adequately to maintain cardiac output. It prevents fatigue and increased workload of the heart, which leads to a decrease in cardiac output and perfusion.

Patient will have maximal cardiac output and stable hemodynamic pressures

Patient will have adequate perfusion o f all body sys tems

Patient will be able to recall instructions correctly

Defining characteristics: communication of discomfort or pain, restlessness, irritability, increased

Patient will be free of pain or pain will be controlled to patient’s satisfaction

Sounds of breath loss in a previously ventilated lung may indicate partial or total lung collapse, especially if the chest tubes have recently been discontinued. Unexpected breath sounds may indicate that fluid or secretions have accumulated in the interstitial spaces or airways, resulting in partial airway occlusion.

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Tracheostomy is considered to prevent ulceration of arteries or other vital tissues, but may need to be avoided because of the potential for contamination of the sternotomy wound by secretions. Sterile technique is recommended due to the proximity of the portal to the heart increasing the potential for systemic infection.

INTERVENTIONS RATIONALFB

CRITICAL CARE NURSING CARE PLANS

Related to: presence of pulse generator, loss of control of heart function, disease process, presence

Defining characteristics: fear of rejection, fear of reaction from others, negative feelings about body,

Aortic Aneurysm

Related to: arterial occlusion, aneurysm, dissecting aneurysm, or operative complications

Related to: pressure exerted o n various structures by aneurysm, infringement o n nerves, surgical pro-

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Related to: lack of understanding, lack of understanding of medical condition, lack of recall Defining characteristics: questions regarding problems, inadequate follow-up of given instructions, misunderstandings, failure to improve previous regimen, development of preventable complications. cations.

AORTIC ANEURYSM

Adult Respiratory

Distress Syndrome CARDS)

Laboratory: cultures to identify causative organisms when bacterial infection is present and to

Chest x-ray: used to evaluate lung fields; early x- rays may be normal or have diffuse infiltrates;

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The patient will have adequate perfusion and cardiac output/index within normal limits for the physiological state. The patient will achieve and maintain a normal and balanced fluid volume status and be hemodynamically stable.

ADULT RESPIRATORY DISTRESS SYNDROME (ARDS)

3 Hypoxemia

DEATH

Chronic Obstructive Pulmonary Disease

Pulmonary function studies: used to evaluate pulmonary status and function, and to identify

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Identifies the patient's ability to compensate for the increased activity and provides a base date from which to plan care. Gradual increases facilitate greater tolerance of activity by balancing the supply and demand of oxygen, and patient cooperation can promote feelings of self-worth and fitness.

Information, Instruction, Demonstration

Defining features: dyspnea, decreased oxygen saturation levels with movement or activity, increased heart rate and blood pressure with movement or activity, feeling tired and weak. Increases in heart rate greater than lol minute or respiratory rate greater than 32 may indicate that the patient has reached his maximum activity limit and further activity may result in circulatory and respiratory dysfunction.

INTERVENTIONS RA'IIONALES

EMPHYSEMA (Pink Puffers)

CHRONIC BRONCHITIS (Blue Bloaters)

The clot then lodges in one or more of the pulmonary arteries and obstructs forward blood flow and oxygen supply to the lung parenchyma. Thrombus formation occurs with blood flow stasis, coagulopathy changes and damage to the endothelium of the vessel walls, and these three factors are known as Virchow's triad.

INTERVENTIONS RA'TIONALES

PULMONARY EMBOLISM

Pneumonia is an acute infection of the lung's terminal alveolar spaces and/or interstitial tissue that results in gas exchange problems. Leukocytes trap bacteria against alveolar walls or other leukocytes so that more organisms are found at the growing margins of consolidation.

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Defining characteristics: pleuritic chest pain aggravated by respiration or coughing, muscle pain, joint pain, restlessness, communication of pain/discomfort. Related to: increased metabolic demand, fever, infection, abnormal taste sensation, anorexia, abdominal distension, nausea, vomiting.

PNEUMONIA

RESOLUTION

Air can also migrate into the area when the esophagus is perforated or a bronchus ruptures, leaking air into the mediastinum (pneumomediastinum). A tension pneumothorax is a life-threatening emergency and occurs when air is admitted into the pleural cavity but not allowed to escape, leading to increased intrathoracic pressure and complete collapse of the lung.

NURSINQ CARE PLANS

Place the chest drainage system below the level of the chest and coil tubing carefully to prevent kinking. Excessive drainage from a dressing may indicate a chest tube malposition, infection, or other problem.

PNEUMOTHORAX

4 Shock

4 DEATH

Status Asthmatieus

INTERVENTIONS RATIONALES Administer bronchodilators as

INTERVENTIONS RATIONALES Monitor for side effects, such as

Related to: dyspnea, change in health status, threat of death

STATUS ASTHMATICUS

Decreased Pa02 Hypoxia

Mechanical Ventilation

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The patient will have arterial blood gases within the normal range for the patient, with no evidence of ventilation/perfusion mismatch. Oximetry uses light waves to identify differences between saturation and reduced hemoglobin in the tissues and can be inaccurate in low blood flow.

INTERVENTIONS RATIONALES INTERSENTIONS RATIONALES

Outcome Criteria INTERWNTIONS RATIONALES Patient will be eupneic, with adequate

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The patient may be fluent in sign language or be able to communicate in writing to draw attention to needs. Writing may be illegible due to disease process or sedation, and may frustrate and tire the patient.

INTERVENTIONS EWTIONALES

Defining characteristics: inability to meet role expectations, inability to meet basic needs, anxiety, apprehension, fear, inability to solve problems, hostility, aggression, inadequate defensiveness. Watch for dependence on others, inability to make decisions, inability to involve oneself in care, or inability to express concerns.

Discharge or Maintenance Evaluation INTERVENTIONS RATIONALES Patient/family will be able to recognize ineffec-

Related to: oral intubation, increased or decreased saliva, inability to swallow, antibiotic-induced

Defining characteristics: oral pain or discomfort, stomatitis, oral lesions, thrush

INTERVENTIONS RATIONALES 0 bserve mouth for missing,

Related to: intubation, inability to swallow, inability to take in food, increased metabolism due to

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Some additives may be unstable after 24 hours, and prolonged infusion of the same solution may promote bacterial growth. Provide instructions on the need for additional nutritional support, the procedures to be performed, and the tests required.

Defining characteristics: inability to wean, lack or inadequacy of spontaneous respirations, negative

Electrolyte replacement or formula change requirements may be modified based on this information. Radiographic confirmation of the placement is mandatory, as well as the exclusion of the procedure after hemo- or pneumothorax.

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Once the patient is able to tolerate 1 to 2 hours without a ventilator at a time, tapering can be continued more quickly. Extubate the patient when he is able to maintain a clear airway and his spontaneous breaths are able to maintain oxygenation and ventilatory status as per protocol.

NEUROLOGICAL SYSTEM

CT scans: used to identify thrombosis or hemorrhagic stroke, tumors or hydrocephalus; may not reveal changes immediately. Angiography is used to identify the site and degree of occlusion or rupture of vessels, assess collateral blood circulation and the presence of AV malformations.

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Defining features: inability to speak, inability to identify objects, inability to understand language, inability to write, inability to choose and use appropriate words, dysarthria. Patients with aphasia have difficulty using and interpreting language, understanding words, and an inability to speak or sign.

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Defining features: inability to perform ADLs, inability to feed oneself, inability to maintain personal hygiene, inability to dress oneself, inability to attend to toileting needs. Assist patient with ADLs as needed and encourage patient to perform tasks he is able to do.

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T he injury may be the result of a direct blow to the head, or may involve acceleration/deceleration injuries. Closed head injuries (BI) occur when blunt trauma to the head causes a neurological deficit or loss of consciousness due to contusion, bleeding or laceration of brain tissue.

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NURSlN6 CARE PLANS

INTERVENTIONS RATIONALES Discharge or Maintenance Evaluation

Information, Instruction Demonstration

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It offers support and helps calm the patient to reduce anxiety and prevent loss of control and panic. It helps maintain a sense of hope for improvement and helps the patient/family determine realis-.

Defining characteristics: fever, tachycardia,

Related to: trauma, lacerations, broken skin, open wounds, invasive procedures, surgery, use of wounds, invasive procedures, surgery, use of steroids, cerebrospinal fluid leakage, nutritional deficiency.

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Patient will be able to consume sufficient nutrients to meet metabolic requirements, and will experience no weight loss. Patient will be able to consume food in sufficient quantities to meet and maintain metabolic requirements.

HEAD INJURIES

CONCUSSION

Spinal Cord Injuries

Defining features: Dyspnea, accessory muscle use, diaphragmatic breathing, decreased tidal volumes, sputum, abdominal distension, abnormal arterial blood gases, apnea, oxygen desaturation. Assess the patient's ability to cough and assist with the abdominal push technique or four coughs as warranted.

Discharge or Maintenance Evaluation

Assess respiratory status for adequate airway and ventilation, rate, nature, depth, increased work of breathing or use of accessory muscles. Paralysis of respiratory muscles can prevent sufficient pleural pressure from being produced to maintain effective coughing.

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Educate the family about rehabilitation therapy, exercises, and repositioning and involve them in the patient's care. It allows adaptation to the patient's medical condition and allows family members to contribute to the patient's well-being.

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Vitamin C and mandelamine can be given to uric acid to inhibit bacterial growth and prevent stone formation. Atropine may be necessary to increase the heart rate if bradycardia is present; Apresolin, hyperstar or procardia may be required to lower blood pressure.

SPINAL CORD INJURIES

JI Decreased venous

6uillain-Barre Syndrome

NURSING CARE PUNS

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Severe changes in blood pressure may occur as a result of autonomic dysfunction due to loss of sympathetic outflow to maintain peripheral vascular tone. Rate changes can occur as a result of vagal stimulation and weakening of the sympathetic innervation of the heart.

Related to: neuromuscular impairment, immobil- ity

Postural hypotension can occur due to diminished reflexes that normally adjust pressure during position changes. Venous stasis may increase the likelihood of deep vein thrombosis forming, and the patient may not be aware of the discomfort associated with paresthesias.

INTERVENTIONS RATIONALB

Defining characteristics: inability to expel all or part of stool, passage of hard stool, frequency less

It helps improve understanding of the complications that can occur with loss of peristalsis due to disease. Determining the severity of a patient's stay during an acute patient's anxiety/fear can help to.

GUILLAIN-B-’ SYNDROME

TRIGGERING EVENT

Status Epilepticus

CT scans: may be done to identify lesions or pre- cipitating factors

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The presence of side effects may indicate that changes in dose or type of medication are needed. Patiedfamily will be able to articulate the understanding of all instructions and adhere to the medical regimen.

Related to: perception of loss of control, ashamed of medical condition

Myoglobin may be present in the urine as a result of prolonged convulsive activity and may lead to kidney failure.

STATUS EPILEPTICUS

Meningitis is an acute infection of the pia and arachnoid membrane that surrounds the brain and spinal cord caused by any type of microorganism. Defining features: presence of infection, elevated white blood cell count, differential shift to the left, positive cultures, hypotension, tachycardia, tremors, fasciculations, seizures, hypoxemia, acid-base disturbances.

MENINGITIS

UentriculostomyhCP Monitoring

MEDICAL CIIRE

Reflex changes may indicate damage at the midbrain or brainstem level. Diuretics and mannirol can be used to draw water out of cerebral cells to decrease edema and ICP.

Information, Instruction, INTERVENTIONS RATIONALES

Demonstration

Related to: invasive monitoring, lack of skin integrity, increased metabolic state, intubation,

Defining characteristics: increased temperature, chills, elevated white blood cell count, differential

Defining features: changes in vital signs, changes in mental status, restlessness, anxiety, sensory deficits, confusion, decreased level of consciousness. Defining features: hypotension, hypertension, heart rate changes, decreased cardiac output index, changes in systemic and peripheral vascular resistance, changes in mental status, hypoxia.

INTERVlENTIONS RATIONALES

Carotid endarterectomy is the removal of a thrombus or plaque from the carotid artery to reduce the risk of stroke in patients who have had a transient ischemic attack (TIA). Defining features: muscle weakness, nerve damage, airway obstruction, hypoxia, dysphagia, facial weakness, facial asymmetry, facial droop, vocal cord paralysis.

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Once the lesion is identified, treatment with Pitressin infusion can be used to control bleeding. Arterial blood gases: can be used to show acid-base imbalances, compensation for decreased blood flow; initially respiratory alkalosis progressing to metabolic acidosis as metabolic wastes accumulate.

Esophagogastroduodenoscopy (EGD): primary diagnostic tool utilized for upper GI bleeding to