Contributed care plans for benign prostatic hypertrophy, care for older adults, ureteral calculi, urinary diversions, and urinary tract obstruction. Contributed care plan for Cancer Care, Psychosocial Support and Psychosocial Support of the Patient's Family and Significant Others.
ORGANIZATION
The All-in-One Nursing Care Planning Resource is a one-of-a-kind book with nursing care plans for all four core clinical areas. The inclusion of pediatric, maternity, and psychiatric-psychiatric nursing in addition to medical-surgical nursing curricula allows students to use one book throughout the entire nursing curriculum.
FEATURES
MEDICAL-SURGICAL NURSING, 1
GENERAL CARE PLANS
RESPIRATORY CARE PLANS
CARDIOVASCULAR CARE PLANS
RENAL-URINARY CARE PLANS
NEUROLOGIC CARE PLANS
ENDOCRINE CARE PLANS
GASTROINTESTINAL CARE PLANS
HEMATOLOGIC CARE PLANS
MUSCULOSKELETAL CARE PLANS
SPECIAL NEEDS CARE PLANS
PEDIATRIC NURSING CARE PLANS, 550
MATERNITY NURSING CARE PLANS, 634
APPENDIXES
BIBLIOGRAPHY, 767
NURSING DIAGNOSES INDEX, 779
INDEX, 787
MEDICAL-SURGICAL NURSING General Care Plans
OVERVIEW/PATHOPHYSIOLOGY
HEALTH CARE SETTING
CARE OF PATIENTS WITH CANCER Lung cancer
Medical-Surgical Nursing
Nervous system tumors
Gastrointestinal malignancies
Neoplastic diseases of the hematopoietic system
MEDICAL-SURGICAL NURSING: General Care Plans Cancer Care 3
Breast cancer
Genitourinary cancers
Head and neck cancers
African American men and Jamaican men of African descent have the highest documented incidence of prostate cancer in the world (American Cancer Society, 2013b). In contrast, the USPSTF (U.S. Preventive Services Task Force, 2012) recommends against the use of routine PSA to test for prostate cancer.
MEDICAL-SURGICAL NURSING: General Care Plans Acute Pain Cancer Care 5
Nursing diagnoses and interventions for general cancer care
ASSESSMENT/INTERVENTIONS RATIONALES
MEDICAL-SURGICAL NURSING: General Care Plans Ineffective Peripheral Tissue Perfusion Cancer Care 7
As noted, advise the patient to obtain a medical alert bracelet that warns against these actions. Make sure compression garments are properly fitted and that the patient understands when and how to use them.
MEDICAL-SURGICAL NURSING: General Care Plans Impaired Skin Integrity Cancer Care 9
Using gentle pressure with swabs or sponges cleans the ulcerated area and protects the granulation tissue. Use soaks (wet dressings) with saline, water, Burrow's solution (aluminum acetate), or hydrogen peroxide on the involved skin.
MEDICAL-SURGICAL NURSING: General Care Plans Stress Urinary Incontinence (or risk for same) Cancer Care 11
Remind the patient to discuss any incontinence problems with the health care provider during follow-up examinations. Assess the impact of diagnosis and treatment on the patient's sexual function and self-concept.
MEDICAL-SURGICAL NURSING: General Care Plans Risk for Disuse Syndrome Cancer Care 13
Advise the patient to wear a medical alert bracelet that warns against injections and tests in the affected arm. Determining the patient's and caregiver's current knowledge base helps the nurse to devise an individualized teaching plan.
MEDICAL-SURGICAL NURSING: General Care Plans Deficient Knowledge Cancer Care 15
Desired outcome: Within the 24 hour period before hospital discharge, the patient verbalizes knowledge about the extent and duration of body changes. A well-informed patient is likely to experience less stress about their treatment, adhere to the treatment regimen accordingly, and report side effects promptly to ensure timely treatment.
Nursing diagnoses and interventions specific to patients undergoing chemotherapy, immunotherapy, and radiation therapy
For patients undergoing estrogen therapy, provide instructions on symptoms related to complications of thromboembolic disorders and myocardial infarction to be reported immediately to the health care provider. If applicable, explain that before starting estrogen therapy, the doctor may prescribe radiation therapy to the areolae of the breasts.
MEDICAL-SURGICAL NURSING: General Care Plans Risk for Infection Cancer Care 17
Instruct the patient to use water-soluble lubricant before sexual intercourse and avoid oral and anal manipulation during sexual activities. If indicated, advise the patient to avoid foods with a high bacterial count (raw eggs, raw fruits and vegetables, foods prepared in a blender that cannot be adequately cleaned); bird, cat and dog excreta; plants, flowers and sources of stagnant water.
MEDICAL-SURGICAL NURSING: General Care Plans Risk for Bleeding Cancer Care 19
If the patient's platelet count is extremely low, straining at stool should be avoided to prevent intra-abdominal bleeding. Advise the patient to abstain from sexual intercourse when the platelet count is less than 50,000/mm3.
MEDICAL-SURGICAL NURSING: General Care Plans Impaired Tissue Integrity Cancer Care 21
In patients taking bleomycin, monitor for the presence of skin thickening and loss of fine motor skills of the hands. Ulceration presents as a generalized, shallow lesion of the epidermal layer and can be induced by various chemotherapeutic agents.
MEDICAL-SURGICAL NURSING: General Care Plans Impaired Skin Integrity Cancer Care 23
Vesicular agents can cause tissue damage and should therefore be administered by a nurse experienced in venipuncture (Payne &. Savarese, 2013). Because time is of the essence to minimize tissue destruction when extravasation occurs, institutional guidelines or extravasation kits should be easily accessible before initiating drug administration.
MEDICAL-SURGICAL NURSING: General Care Plans Risk for Injury Cancer Care 25
Chemotherapy spills can result in inadvertent exposure to other healthcare professionals, the public, other patients, and the environment. The committee approves certain rooms that can be used for patients undergoing radioactive treatment in order to minimize exposure to employees and other patients.
MEDICAL-SURGICAL NURSING: General Care Plans Imbalanced Nutrition: Less Than Body Requirements Cancer Care 27
Assess the patient's pattern of nausea and vomiting: onset, frequency, duration, intensity, and amount and character of vomiting. Instruct the patient to take an antiemetic, if prescribed, 1 hour before chemotherapy and to continue taking the medication as prescribed.
MEDICAL-SURGICAL NURSING: General Care Plans Impaired Oral Mucous Membrane Cancer Care 29
Following the instructions, the patient verbalizes the early signs and symptoms of esophagitis, alerts the health care team as soon as they occur, and identifies measures to maintain nutrition and comfort. Teach the patient the early signs and symptoms of esophagitis and stomatitis and the importance of promptly reporting symptoms if they occur.
MEDICAL-SURGICAL NURSING: General Care Plans Impaired Urinary Elimination Cancer Care 31
Maintaining adequate urine output for 48 hours prevents high concentrations of drug metabolites in the kidneys and bladder. Notify healthcare provider immediately if urine output falls below 100 mL/hour.
MEDICAL-SURGICAL NURSING: General Care Plans Deficient Knowledge Cancer Care 33
Encourage the patient to take analgesics regularly for pain or to request an analgesic before the pain becomes severe. The patient should be instructed in the procedures for cleaning the humidifier to prevent the introduction of bacteria.
MEDICAL-SURGICAL NURSING: General Care Plans Deficient Knowledge Cancer Care 35
Identifying the preferred learning methods and the amount of information they would like to receive allows the nurse to develop a teaching plan based on this information. To ensure that retention has occurred, patients must be able to verbalize accurate knowledge of route of administration, duration of treatment, schedule, frequency of laboratory tests, most common adverse effects and toxicities, follow-up care, and appropriate self-care. .
MEDICAL-SURGICAL NURSING: General Care Plans Disturbed Body Image Cancer Care 37
Teach the patient and relatives to report early symptoms of hearing loss that the patient may experience. Assess for behavioral and physiological indicators of pain at frequent intervals (eg, during scheduled assessments of vital signs [VS]).
PART I: Medical-Surgical Nursing
MEDICAL-SURGICAL NURSING: General Care Plans Impaired Comfort Pain 41
Older adults who are opioid naïve and patients with coexisting conditions are at higher risk for respiratory depression. Therefore, patients who are opioid naïve (or have coexisting conditions) are at greater risk of respiratory depression than the patient who has received an opioid for a week or more.
MEDICAL-SURGICAL NURSING: General Care Plans Impaired Comfort Pain 43
Enhance the effectiveness of the medication by recommending non-pharmacological methods of pain management, including weight loss, physiotherapy, cognitive behavioral therapy, acupuncture, massage and biofeedback. Many of these techniques can be taught and implemented to the patient and their partner.
Nursing diagnoses for preoperative patients
If patient-controlled analgesia (PCA) or patient-controlled epidural anesthesia (PCEA) will be prescribed, the patient must provide a return demonstration of the use of the delivery device. Knowing visiting hours will likely reassure them that they will have access to the patient after surgery.
MEDICAL-SURGICAL NURSING: General Care Plans Risk for Injury Perioperative Care 47
Ensure patient identification wristband, blood transfusion wristband and allergy wristband are in place. Sedatives administered preoperatively can alter mental status and coordination, increasing the patient's risk of injury.
MEDICAL-SURGICAL NURSING: General Care Plans Ineffective Airway Clearance Perioperative Care 49
Nursing diagnoses for postoperative patients
If appropriate, encourage the patient to refrain from smoking for at least 1 week after surgery. Assist the patient with turning and deep breathing/coughing exercises q2h until the patient is ambulatory.
MEDICAL-SURGICAL NURSING: General Care Plans Risk for Aspiration Perioperative Care 51
Desired outcome: The patient is free of infection, as evidenced by normothermia; heart rate (HR) 100 bpm or less; RR 20 breaths/min or less with normal depth and pattern (eupnea); Change IV line and site if there is evidence of infection and according to agency protocol (q48-72h).
MEDICAL-SURGICAL NURSING: General Care Plans Risk for Infection Perioperative Care 53
Administer and regulate IV fluids and electrolytes as prescribed until the patient can resume oral intake. Both sensible and insensible losses should be determined to provide a complete assessment of the patient's fluid volume status.
MEDICAL-SURGICAL NURSING: General Care Plans Risk for Shock Perioperative Care 55
Weigh the patient daily with the same weight and the same type and amount of bedding. Repeat information until the patient is fully awake and oriented (usually several hours, but may be days in heavily sedated or otherwise silenced individuals).
MEDICAL-SURGICAL NURSING: General Care Plans Risk for Impaired Skin Integrity Perioperative Care 57
Desired outcome: Optimally, upon discharge from the hospital (depending on the type of surgery), the patient returns to pre-surgery physical mobility, as evidenced by the ability to move, transfer and move in bed independently or with minimal assistance. to walk. Begin bed-to-chair movement and ambulation as soon as possible after surgery, depending on postoperative requirements, type of surgery, and patient's recovery from anesthesia.
MEDICAL-SURGICAL NURSING: General Care Plans Constipation Perioperative Care 59
The patient rates perceived exertion (RPE) at 3 or less on a scale of 0 (none) to 10 (maximum) and maintains muscle strength and joint range of motion (ROM). To promote optimal conditioning, activity should be increased to match the patient's increased tolerance.
Bedrest
Move on to active-assisted exercises where you support the joints while the patient initiates muscle contraction. Caution: Stop exercise if the patient becomes excessively short of breath, has a rapid pulse, faints, or experiences severe pain, dizziness, or lightheadedness.
MEDICAL-SURGICAL NURSING: General Care Plans Risk for Disuse Syndrome Prolonged Bedrest 63
Out of bed to chair
When the head of bed (HOB) needs to be elevated 30 degrees, extend the patient's shoulders and arms and use pillows to support the position. With the patient in the lateral position, extend the lower leg from the hip.
MEDICAL-SURGICAL NURSING: General Care Plans Ineffective Peripheral Tissue Perfusion Prolonged Bedrest 65
If signs of DVT/VTE develop, further evaluation is needed to protect the patient from a pulmonary embolism or clot that could compromise the limb. If the patient is at risk for DVT/VTE, raise the foot of the bed 10 degrees.
MEDICAL-SURGICAL NURSING: General Care Plans Risk for Ineffective Cerebral Tissue Perfusion Prolonged Bedrest 67
If dangling of the legs is tolerated, have the patient stand at the bedside with two staff members present. The patient reports that the normal pattern and nature of intestinal elimination returned within 3-5 days of this diagnosis.
MEDICAL-SURGICAL NURSING: General Care Plans Ineffective Role Performance Prolonged Bedrest 69
As the patient's endurance improves, engage in appropriate diversionary activities such as puzzles, model kits, crafts, etc. Increase the patient's involvement in self-care to gain a sense of purpose, achievement, and control.
MEDICAL-SURGICAL NURSING: General Care Plans Ineffective Sexuality Patterns Prolonged Bedrest 71
Assess how fatigue affects the patient's emotional status and ability to perform activities of daily living (ADL). Some or all of the patient's usual sleep patterns can be included in the care plan.
MEDICAL-SURGICAL NURSING: General Care Plans Ineffective Coping Psychosocial Support 75
Lack of understanding of the patient's maladaptive coping can lead to unhealthy interaction patterns and contribute to anxiety in the family. This assessment helps to develop a care plan adapted to the patient's needs, which will optimally reduce the feeling of powerlessness.
MEDICAL-SURGICAL NURSING: General Care Plans Spiritual Distress Psychosocial Support 77
Refer the patient for help with decision-making if he or she is struggling with treatment-related decisions. Assess the patient's grief reactions, and identify the potential for dysfunctional grief reactions (eg, absence of emotion, hostility, avoidance).
MEDICAL-SURGICAL NURSING: General Care Plans Disturbed Body Image Psychosocial Support 79
Involve the patient and/or caregiver in assessing the patient's ability to read, write, and understand English. An interpreter facilitates effective communication, promotes informed consent, and enables the patient to ask questions.
MEDICAL-SURGICAL NURSING: General Care Plans Social Isolation Psychosocial Support 81
Desired Outcome: Prior to procedures or discharge (as appropriate), patient verbalizes understanding regarding current health condition and therapies. This assessment enables the development of an individualized learning plan, as well as the correction of misperceptions and misinformation.
MEDICAL-SURGICAL NURSING: General Care Plans Deficient Knowledge Psychosocial Support 83
This information increases the family's knowledge of the patient's medical condition and helps alleviate fear of the unknown. Inform the family at frequent intervals about the patient's current medical condition, therapies, and prognosis.
MEDICAL-SURGICAL NURSING: General Care Plans Risk for Aspiration Older Adult Care 93
Assess the patient's swallowing ability by placing your thumb and index finger on either side of the laryngeal protuberance and asking the patient to swallow. Make sure the patient has dentures, if applicable, and that they fit properly.
MEDICAL-SURGICAL NURSING: General Care Plans Risk for Deficient Fluid Volume Older Adult Care 95
If the patient is receiving IV therapy, assess the cardiac and respiratory systems for signs of overload. If the oral reading seems unreliable, rectal readings can help ensure an accurate determination of the patient's body temperature.
MEDICAL-SURGICAL NURSING: General Care Plans Hypothermia Older Adult Care 97
If the patient's temperature falls below 35°C (95°F), rewarm the patient internally by giving warm oral or intravenous fluids. The patient's temperature will not return to normal unless the underlying condition has been treated.
MEDICAL-SURGICAL NURSING: General Care Plans Disturbed Sleep Pattern Older Adult Care 99
If the patient's usual bowel movement occurs in the early morning, use the patient's gastrocolic or duodenocolic reflex to stimulate colonic emptying. If the bowel movement occurs in the evening, take it just before the appropriate time.
MEDICAL-SURGICAL NURSING: General Care Plans Adult Failure to Thrive Older Adult Care 101
ASSESSMENT/INTERVENTIONS RATIONALE
Physical and occupational therapists can help analyze physical limitations/strengths and the potential for improvement with a program or aid.
OVERVIEW
ASSESSMENT/INTERVENTION RATIONALE
Discussing the patient's advanced care planning helps avoid a crisis-like approach to advanced disease management. Explain that palliative care can be provided along with advanced disease management by the patient's primary care provider and is reimbursed as routine medical treatment.
MEDICAL-SURGICAL NURSING: General Care Plans Impaired Comfort Palliative and End-of-Life Care 105
Ladder
MEDICAL-SURGICAL NURSING: General Care Plans Impaired Comfort Palliative and End-of-Life Care 107
Desired Outcome: The patient and family recognize that they accept the normal process of death and dying and understand the effects on the human body.
ASSESSMENTS/INTERVENTIONS RATIONALES
MEDICAL-SURGICAL NURSING: General Care Plans Impaired Gas Exchange Palliative and End-of-Life Care 109
Help the patient and family identify past successful coping strategies that have worked in stressful situations. Allow the family to express culturally specific concerns and issues about the patient's impending death.
ASSESSMENT
Airflow limitation is progressive and associated with an abnormal inflammatory response of the lung to noxious particles or gases and is characterized by chronic inflammation throughout the airways, parenchyma, and pulmonary vasculature. The chronic airflow limitation characteristic of COPD is caused by a mixture of inflammation of the small airways (bronchitis) and parenchymal destruction (emphysema), the relative contributions of each varying from person to person.
DIAGNOSTIC TESTS
Desired outcome: After treatment/intervention, the patient's breathing pattern improves as evidenced by reduction in or absence of reported dyspnea and related symptoms. Desired Outcomes: Optimally within 1-2 hours after treatment/intervention or by discharge, the patient has adequate gas exchange as evidenced by respiratory rate (RR) of 12-20 breaths/min (or values consistent with patient's baseline).
MEDICAL-SURGICAL NURSING: Respiratory Care Plans Activity Intolerance Chronic Obstructive Pulmonary Disease (COPD) 113
Desired outcome: At least 24 hours before discharge from the hospital, the patient is adequately nourished, as evidenced by the intake of at least 50% of the prescribed calories/meals. Cachexia (loss of muscle and fat despite adequate nutrition) is associated with increased mortality in individuals with COPD.
MEDICAL-SURGICAL NURSING: Respiratory Care Plans Imbalanced Nutrition: Less Than Body Requirements Chronic Obstructive Pulmonary Disease (COPD) 115
White blood cell (WBC) count: Will be elevated (more than 12,000/mm3) in the presence of bacterial pneumonia. Findings may indicate hypoxemia (PaO2 less than 80 mm Hg) and hypocarbia (PaCO2 less than 32-35 mm Hg), with a resultant respiratory alkalosis (pH greater than 7.45) in the absence of underlying pulmonary disease.
Nursing diagnosis for patients at risk for developing pneumonia
Aspiration precautions include maintaining the Hob at 30-degree elevation, turning the patient on the side rather than the back, and using continuous rather than bolus feeding when the patient is receiving enteral nutrition. Discard any liquid that has condensed in the tube; do not allow it to drain back into the reservoir or into the patient.
Nursing diagnoses for patients with pneumonia
Keep the head of the bed (HOB) at a height of 30 to 45 degrees and turn the patient into a side-lying position. Saline instillation can cause bacteria to move to the lower lung fields, increasing the risk of inflammation and invasion of sterile tissue.
MEDICAL-SURGICAL NURSING: Respiratory Care Plans Ineffective Airway Clearance Pneumonia 119
The patient's inability to breathe deeply is a sign of the need for this therapy. The patient slowly and deeply inhales 2 × the normal respiratory volume and at the end of the inhalation holds the breath for at least 5 seconds.
MEDICAL-SURGICAL NURSING: Respiratory Care Plans Deficient Fluid Volume Pneumonia 121
PNEUMOTHORAX
HEMOTHORAX
Desired outcome: After intervention, the patient becomes eupneic; lung expansion is noted on a chest x-ray.
Assessment
The oscillations stop when the lungs re-expand or there is a kink or obstruction in the chest tube. This gauze pad is placed over the insertion site if the chest tube is dislodged.
MEDICAL-SURGICAL NURSING: Respiratory Care Plans Acute Pain Pneumothorax/Hemothorax 125
The formation of thrombi is the result of the following factors: blood stasis, changes in blood clotting factors and damage to vessel walls. In chronic PE, patients develop slow and progressive dyspnea resulting from pulmonary hypertension.
HISTORY AND RISK FACTORS
Pulmonary embolism (PE) is a blockage of the pulmonary artery or one of its branches by substances (eg blood clot, fat, air, amniotic fluid) originating elsewhere in the body. Signs and symptoms are often nonspecific and variable, depending on the extent of the obstruction and whether the patient has a stroke as a result of the obstruction.
Findings specific for fat emboli
Pulmonary ventilation-perfusion scan: Used to detect abnormalities of ventilation or perfusion in the pulmonary system. If the scan shows a mismatch of ventilation and perfusion (ie, pattern of normal ventilation with decreased perfusion), vascular obstruction is suggested.
History and risk factors for fat embolus
Pulmonary angiography: The definitive study for PE, this is an invasive procedure that involves catheterization of the right heart and injection of dye into the pulmonary artery (PA) to visualize pulmonary vessels. More specific findings are abnormal vessel diameters (eg, obstruction of the right PA will cause dilatation of the left PA) and shapes (eg, the affected vessel may taper to a sharp point and disappear).
General findings for pulmonary emboli
MEDICAL-SURGICAL NURSING: Respiratory Care Plans Impaired Gas Exchange Pulmonary Embolus 129
For patients receiving warfarin therapy, consult the pharmacist to obtain specific information regarding the patient's medication profile. Discuss with the patient and significant others the effects of anticoagulant therapy and the importance of promptly reporting the presence of bleeding.
MEDICAL-SURGICAL NURSING: Respiratory Care Plans Deficient Knowledge Pulmonary Embolus 131
In 2011, there were fewer than 11,000 reported cases of tuberculosis in the United States, more than half of which were among foreign-born individuals. Individuals who have emigrated from parts of the world with high tuberculosis rates are also more likely to develop LTBI than individuals born in the United States.
MEDICAL-SURGICAL NURSING: Respiratory Care Plans Deficient Knowledge Pulmonary Tuberculosis 135
Clinical indicators of ARF vary depending on the underlying disease process and severity of failure. Abdominal aortic aneurysm: A pulsatile, nontender mass can be palpated on either side of the abdominal midline.
MEDICAL-SURGICAL NURSING: Cardiovascular Care Plans Risk for Ineffective Gastrointestinal Perfusion Aneurysms 139
Determine permitted activity and exercise with the health care team and discuss this with the patient. Teach the patient how to assess peripheral pulses, warmth, sensation, and color of the lower extremities (LE).
MEDICAL-SURGICAL NURSING: Cardiovascular Care Plans Ineffective Peripheral Tissue Perfusion (or risk for same) Atherosclerotic Arterial Occlusive Disease 143
Complete blood count (CBC): Hematocrit (Hct) and hemoglobin (Hgb) may be increased in severe dehydration or decreased in the presence of hemorrhage. Monitor urine output hourly and check weight daily; notify health care provider of significant findings, including urine output less than 30 mL/hr (0.5 mL/kg/hr) in the presence of adequate intake and/or weight gain.
MEDICAL-SURGICAL NURSING: Cardiovascular Care Plans Risk for Electrolyte Imbalance Cardiac and Noncardiac Shock (Circulatory Failure) 147
Assess the patient's level of knowledge about the diagnosis and surgical procedure and provide information as needed. Instruct and demonstrate deep breathing and coughing techniques; ask the patient to demonstrate a reversal.
MEDICAL-SURGICAL NURSING: Cardiovascular Care Plans Activity Intolerance Cardiac Surgery 151
Echocardiogram: Assesses ventricular function, chamber size, valve function, ejection fraction, wall motion, and hemodynamic measurements. Stress tests are prescribed to assess coronary artery flow, valvular function, and wall motion abnormalities.
Medical-SurgicalNursing
MEDICAL-SURGICALNURSING:Cardiovascular Care Plans ActivityIntolerance Coronary Artery Disease 155
Desired Outcome: Within the 24-hour period prior to hospital discharge, the patient demonstrates dietary awareness by planning a 3-day menu that includes and excludes appropriate foods. Desired Outcome: Within the 24-hour period prior to hospital discharge, the patient verbalizes understanding of the purpose, precautions, and side effects of nitrates.
MEDICAL-SURGICALNURSING:Cardiovascular Care Plans DeficientKnowledge Coronary Artery Disease 157
Desired Outcome: In the 24-hour period prior to hospital discharge, the patient verbalizes knowledge of the course of CAD and concomitant lifestyle consequences.
MEDICAL-SURGICALNURSING:Cardiovascular Care Plans DeficientKnowledge Coronary Artery Disease 159
Nursing diagnoses for patients undergoing cardiac catheterization procedure
Assess the patient's health care literacy (language, reading, . comprehension).Evaluatecultureandculturallyspecificinformation. If symptoms of decreased cardiac output occur, prepare to transfer the patient to intensive care.
MEDICAL-SURGICAL NURSING: Cardiovascular Care Plans Deficient Knowledge Dysrhythmias and Conduction Disturbances 167
The heart becomes more spherical (dilated) due to myofibril elongation, cell slippage, fibrosis, and myocyte death. These progressive changes in the size, shape and structure of the heart muscle are called remodeling.
Acute decompensated heart failure
Acute pulmonary edema
Other causes of heart failure
ASSESSMENT General
Teach the patient to take slow, deep breaths. Taking deep breaths increases myocardial oxygenation and improves At least 48 hours before discharge, the patient is free of new dysrhythmias, exhibits no significant changes in mental status, and remains oriented to person, place, and time.
MEDICAL-SURGICALNURSING:Cardiovascular Care Plans DeficientKnowledge Heart Failure 175
Desired Outcome: In the 24-hour period prior to hospital discharge, the patient verbalizes an understanding of the purpose, precautions, and side effects associated with digoxin therapy.
MEDICAL-SURGICALNURSING:Cardiovascular Care Plans DeficientKnowledge Heart Failure 177
Normal blood pressure: systolic blood pressure (SBP) less than 120 mm Hg and diastolic blood pressure (DBP) less than 80 mm Hg. Learn the importance of assessing BP at regular intervals and adherence to prescribed medication therapy.
MEDICAL-SURGICAL NURSING: Cardiovascular Care Plans Activity Intolerance Pulmonary Arterial Hypertension 183
