Page 659 - Cardiac Nursing

CHAPTER 26 / Mechanical Circulatory Assist Devices 635

Nursing Care Plan 26-1 (continued)

Nursing Diagnosis 3 ç Sensory/perceptual alterations: sensory overload related to intensive care unit environment and
the need for frequent monitoring, manifested by disorientation, anxiety, restlessness, and sleep-
lessness.

Nursing Goal 3 ç To reduce or eliminate excessive sensory stimuli that might impair sleep–wake cycles

Outcome Criteria ç 1. There will be no excessive or unnecessary noise in patient’s environment.
2. Patient will have progressive blocks of undisturbed time for sleep.

NURSING INTERVENTIONS RATIONALE
1. Maintain monitor “bleep” volume at lowest audible level. 1–3. Unnecessary noise disturbs patient’s sleep and creates
2. Minimize amount of extraneous noise from other higher levels of stress during wakefulness.
equipment in patient’s room.
3. Minimize unnecessary noise caused by staff conversations
in patient’s room.
4. Turn down lights in patient’s room during the night. 4. Darkening the room during the night helps patient dis-
tinguish day from night and provides a better environ-
ment for sleep at night.
5. Organize nursing care so patient has uninterrupted time 5. Organized care can provide patients with up to 2-hour
for sleep during the night, amount to be determined by periods when it is unnecessary directly to touch the
patient’s condition. patient. As the patient’s condition improves, longer
blocks of time are feasible.

Nursing Goal 2 ç To assist patient with maintaining orientation and some degree of control of self.
Outcome Criteria ç 1. Patient will be oriented to date, time, and place.
2. Patient will be able appropriately to interpret his or her environment.
NURSING INTERVENTIONS RATIONALE

1. Talk with patient while administering care. Explain noises, 1. Explanations assist the patient to interpret the environment
activity, and procedures to be done. appropriately and minimize stress and anxiety associated
with a fear of the unknown.
2. Involve patient in decision making about care if possible 2. Involvement in decisions helps the patient maintain some
(e.g., which direction to turn next). When patient is able, degree of control.
teach patient to do ankle flexion exercises and deep
breathing exercises, which can be done independently by
patient.
3. Frequently inform patient of the time and date and orient 3. Frequently reorienting the patient helps prevent disorien-
to surroundings. tation.
4. Place familiar objects such as pictures within patient view; 4. Familiar objects may help maintain orientation.
involve family in the process.

Nursing Diagnosis 4 ç Ineffective family coping related to inadequate support, knowledge deficit, fear of patient dying,
and fear of the intensive care unit environment, manifested by requests for help or inappropri-
ate behavior.

Nursing Goal ç To assist family with development of ability to cope.
Outcome Criteria ç 1. The family members will acknowledge their fears and concerns.
2. The family will verbalize a decrease in their level of fear and will appear calmer.
3. The family will demonstrate an ability to cope effectively.