Transcript Care Plan Exercise - Texas A&M University Corpus Christi

Care Plan Exercise
Cristi Day RN, MSN, FNP-C
Texas A&M University –
Corpus Christi
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.

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
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
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
RR
24
SOB
Fees like
he going to
die
Ineffective Tissue Perfusion: Outcome Goals
1.
2.
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.
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
RR
24
Fees like
he going to
die
SOB
1.
2.
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
Ineffective Tissue Perfusion: Interventions
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/MERLIN/Gulanick/Const
ructor/index.cfm?plan=55
Teach client/family about medications, their
regimen, actions, and side effects. RA:
Appropriate instruction increases accuracy &
safety of medication administration. (A&L p 904)
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)
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=5
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
RR
24
Fees like
hes going
to die
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)
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)
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
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.
Ineffective Tissue Perfusion: Evaluation
1.
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.
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.
Activity Intolerance - Cont’d

Related Factors (R/T): Bed rest or
immobility, generalized weakness,
sedentary lifestyle, imbalance between
oxygen supply and demand.
Activity Intolerance –
Nursing Diagnosis Statement
Activity Intolerance R/T imbalance
between oxygen supply and
demand (CHF decreased Cardiac
Output) AEB fatigue, exertional
dyspnea.
Activity Intolerance : Care Map
Activity Intolerance R/T
imbalance between
oxygen supply and
demand (CHF decreased
Cardiac Output) AEB
fatigue, exertional
dyspnea.
c/o
fatigue
Exertional
dyspnea
Activity Intolerance : Outcome Goals
1.
2.
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.
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)
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)
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)
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)
Activity Intolerance : Care Map
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)
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)
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)
c/o
fatigue
Exertional
dyspnea
1.
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)
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)
Client will
demonstrate
increased activity
intolerance
(decrease report of
fatigue and decreased
exertional dyspnea by
time of discharge.
2.
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.
Activity Intolerance : Evaluation
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.
1.
2.
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.
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
States desired patient outcome criteria
Realistic time frame
Long and Short Term Goal,
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