Page 554 - Cardiac Nursing

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530 PA R T I V / Pathophysiology and Management of Heart Disease
For Goal 3 agents) as ordered, and continuously evaluate the patient’s re-
1. Provide small portions of easily digested, low-sodium, low sat- sponse to therapy.
urated fat foods. 3. Provide a restful environment; promote the patient’s physical
2. Provide a restful environment; as needed, assist the patient in a comfort by elevating head of bed to 20 to 30 degrees or higher,
supportive, calm, competent manner with activities of daily living. or by providing a cardiac chair (depending on BP response),
3. Teach patient to exhale with physical movement; as necessary. and by giving individualized basic nursing care.
4. Offer stool softeners and laxatives to prevent straining with For Goal 3
bowel movements, and teach patient relaxation techniques.
1. Provide small portions of easily digestible, low-sodium, low sat-
urated fat foods. Provide a restful environment; as needed, as-
Outcome Criteria sist the patient in a supportive, calm, competent manner with
Goal 1: Arrhythmias and conduction disturbances and signs and activities of daily living.
symptoms of heart failure are detected at onset. 2. Teach patient to exhale with physical movement.
Goal 2: Immediately after intervention, the patient’s cardiac 3. Offer stool softeners and laxatives to prevent straining with
rate and rhythm return to patient’s normal range. Patient states bowel movements. Teach patient to recognize precipitating fac-
that palpitations are relieved or reduced; patient appears comfort- tors of decreased systemic tissue perfusion and to alter behavior
able; and BP is returning or has returned to baseline level. S 3 or accordingly.
S 4 gallops or the murmurs of mitral regurgitation disappear or do
not increase in intensity; crackles are eliminated or reduced; and Outcome Criteria
activity tolerance is maintained or improved.
Goal 3. The patient denies chest discomfort. The patient ap- Goal 1
pears comfortable. Heart and respiratory rates and BP are within Signs and symptoms of decreased systemic tissue perfusion are de-
the patient’s normal range. The skin is warm and dry. There are tected early.
no S 3 or S 4 gallops, no murmur of mitral regurgitation, and no Goal 2
crackles. The patient’s activity tolerance is maintained.
BP and pulse pressure are returning or have returned to baseline
level. Respiratory rate and rhythm are returning or have returned
Decreased Systemic Perfusion to patient’s baseline. Patient remains fully alert and oriented, with-
out personality change. Urine output remains greater than 250 cc
Diagnosis per 8 hours. Patient’s complaints of fatigue are reduced. Patient is
Decreased systemic tissue perfusion related to a decrease in cardiac able to carry out activities of daily living within prescribed activ-
output from arrhythmias and conduction disturbances and from ity limits. Extremities remain warm, dry, and of normal color.
heart failure, manifested by abnormal pulse rate and rhythm; ab-
normal respiratory rate and rhythm; deterioration of other hemo- Goal 3
dynamic parameters; decreased mentation; decreased urine out- Normal sinus rhythm without arrhythmia or conduction distur-
put; individually defined undue or excess fatigue; and moist, cool, bance is maintained. BP and pulse pressure are maintained at pa-
cyanotic skin. tient’s baseline level. Respiratory rate and rhythm are maintained at
patient’s baseline. Patient remains fully alert and oriented, without
Goals mental status change. Urine output remains greater than 250 cc per
1. Detect early manifestations and etiologies of decreased systemic 8 hours. Patient does not complain of worsening fatigue. Patient is
tissue perfusion. able to carry out activities of daily living within prescribed activity
2. Reduce or eliminate manifestations of decreased systemic tissue limits. Extremities remain warm, dry, and of normal color.
perfusion.
3. Prevent manifestations of decreased systemic tissue perfusion.
Fear or Anxiety
Interventions Diagnosis
Interventions are designed to detect the manifestations of the imbal- Decreased systemic tissue perfusion related to a decrease in cardiac
ance between systemic oxygen supply and demand and to improve output from arrhythmias and conduction disturbances and from
this imbalance by restoring the balance between myocardial oxygen heart failure, manifested by abnormal pulse rate and rhythm; abnor-
supply and demand. Interventions to meet each goal include: mal respiratory rate and rhythm; deterioration of other hemodynamic
parameters; decreased mentation; decreased urine output; individu-
For Goal 1
On admission, every 4 hours, and during chest discomfort, assess, ally defined undue or excess fatigue; and moist, cool, cyanotic skin.
document, and report to the physician the following: abnormal Goals
heart rate and rhythm; hypotension; narrowing pulse pressure; ab- 1. Detect early manifestations and etiologies of decreased systemic
normal respiratory rate and rhythm; decreased mentation; decreased tissue perfusion.
urine output; increasing fatigue; and moist, cool, cyanotic skin.
2. Reduce or eliminate manifestations of decreased systemic tissue
For Goal 2 perfusion.
1. Immediately reduce patient’s physical activity to the level of ac- 3. Prevent manifestations of decreased systemic tissue perfusion.
tivity before occurrence of manifestations of decreased systemic
tissue perfusion. Interventions
2. Administer oxygen and antiarrhythmic and other medications Interventions are designed to detect the manifestations of the imbal-
(positive inotropic, afterload-reducing, and preload-reducing ance between systemic oxygen supply and demand and to improve