Problem#4: Ineffective tissue perfusion (cardiac) r/t myocardial cell wall injury

Cues
S> The patient may
verbalize:
sense
of
impending doom
O> The patient
manifested:
dilated left
ventricle
with
segmental
wall
motion
abnormalities
severely
depressed
left
ventricular systolic
function with at
least grade 3 left
ventricular diastolic
dysfunction
- elevated CKMB
levels (47.4 ng/dl)
- hgb levels below
normal (124 g/dl)
- hct levels below
normal (0.39 g/dl)
- chest pain
- with
oxygen
hooked via nasal
cannula regulated
at 2 lpm
with condom
catheter attached
to urine bag
continuous
cardiac monitoring
> The patient may
manifest:
- confusion
- lethargy
- abnormal ABGs
- cyanosis

Nursing
Diagnosis

Scientific
Explanation

Ineffective
tissue perfusion
(cardiac)
r/t
myocardial cell
wall injury

Ineffective tissue
perfusion
is
a
decrease
in
Oxygen resulting
in the failure to
nourish the tissues
and
capillaries.
Myocardial
Infarction occurs
when insufficient
blood
supply
reaches the heart
thus
causing
damage to the
heart
muscle.
Possible
contributing factors
include dilation of
the left ventricle
which inhibits its
normal
pumping
ability,
thus
reducing the blood
supply that the
heart and tissues
demand. Also, in
cases
of
low
hemoglobin
and
hematocrit levels,
the tissues would
not receive the
adequate amount
of oxygen they
need, and if left
untreated
would
result to ischemia
which may lead to
an
infarction.
Certain
cardiac
markers may be
used to diagnose
an infarction such
as CK-MB. Such
would confirm an
infarction if levels
are seen elevated.

Objectives

Nursing
Interventions

Rat

Short term:
After 4 hours of NI,
the
patient
will
verbalize
understanding
of
condition
and
therapy regimen and
demonstrate lifestyle
changes to improve
circulation.

>Establish rapport

>to
gain
cooperation

>Assess
condition

>to determ

Long term:
After 4 days of NI,
the
patient
will
demonstrate
increased perfusion
as
individually
appropriate.

>
Assess
for
possible causative
factors related to
temporarily impaired
arterial blood flow

patients

>to obtain b
>Monitor VS
>Review
baseline
ABGs, electrolytes,
BUN/Cr,
cardiac
enzymes

> Maintain optimal

cardiac output

> to not
impairment
involvemen

> Early det

facilitates
effective tre

> This ens

perfusion o
Support m
to facilita
circulation
of
affe
antiembolis

> to conse
lowers
demands

> to ma
perfusion
> Encourage quiet,
restful atmosphere
> Caution patient to
avoid activities that
increase
cardiac
workload.
Encourage
early
ambulation,
if
possible
> Explain possible
factors that may
boost
the
occurrence
of
ineffective
tissue
perfusion
> Identify changes

> To impo
on the patie

> To evaluat
complication

>Drugs that
perfusion als
risk of adver

>Information

r/t
systemic
peripheral
alterations
circulation
>Administer
medications
caution

or
in

with

>Discuss individual
risk factors

client to mak
choices abo
risk factors a
commitment
changes, as
to prevent co
manage sym
present

>Facilitates
of hypertens
major risk fa
damage of b
or organ dys

>Instruct in blood
pressure monitoring
at home

Problem#5: Decreased Cardiac Output

Cues
S> the patient may
verbalize:
shortness
of
breath /dyspnea
- fatigue
- anxiety
O>
The
patient
manifested:
- dilated left ventricle
with segmental wall
motion abnormalities
- severely depressed
left ventricular systolic
function with at least
grade 3 left ventricular
diastolic dysfunction
- with oxygen hooked
via nasal cannula
regulated at 2 lpm
with
condomcatheter
attached to urine bag
- continuous cardiac

Nursing
Diagnosis

Scientific
Explanation

Decreased
cardiac output
r/t
altered
stroke volume

The hypoxic tissue

in
myocardial
infarction within the
border zone may
become a site for
generating
arrhythmias.
Infracted
tissue
does not contribute
to
tension
generation during
systole,
and
therefore can alter
ventricular systolic
and
diastolic
function
and
disrupt
electrical
activity within the
heart.
Without
improvement, the
heart muscles may
undergo
remodeling
such
as
hypertrophy,

Objectives
Short term:
After 4 hours of NI,
the
patient
will
participate
in
activities
that
decrease
the
workload of the
heart
such
as
stress management
or
therapeutic
medication regimen
program

Long term:
After 4 days of NI,
the
patient
will
display
hemodynamic
stability
AEB
normalization
of
ECG tracings and

Nursing Interventions

>Establish rapport

> to g
coopera

>Assess
condition

> to d
and sym

patients

>Monitor VS

> to o
data

>Monitor
ECG
for
dysrrhythmias,
conduction defects and
for heart rate

> decre
output
change
perfusio
dysrhyt

>Monitor
cardiac
rhythms continuously
>Encourage patient to
decrease intake of
caffeine,
cola
and
chocolates

>
to
effectiv
medicin

> caffe
stimula
adverse
cardiac

monitoring

losing its normal

pumping
ability,
thus may cause
inadequate blood
to meet the needs
of
the
bodys
tissues.
Cardiac
output and tissue
perfusion
are
interrelated, thus a
decrease
in
cardiac output may
bring
about
cyanosis,
pallor
and
prolonged
capillary
refill.
There may also be
fatigue
and
shortness of breath
as there is not
enough
oxygen
supplied to the
tissues.

The
patient
may
manifest:
- dysrhythmias
- ECG changes
- cyanosis
- pallor
- prolonged capillary
refill
- decreased peripheral
pulses
- variations in blood
pressure readings

blood
readings

pressure
>Observe skin color,
temperature, capillary
refill
time
and
diaphoresis

>
vasoco
result
clammy
prolong
refill ti
cardiac
and dec
output

> to ma
nutrition
balance
>Monitor intake and
output and calculate 24
hour fluid balance
>Administer
supplemental
as indicated

> to
adequa

> to pro
oxygen

>Administer medicines
as prescribed by the
physician

> to de
consum

>Promote
adequate
rest by decreasing
stimuli providing quiet
environment

>
occurre
orthosta
hypoten

>Encourage changing
positions
slowly,
dangling legs before
standing

>
res
assist w
fluid
hyperte
improvi
output

>Instruct client & family

on fluid and diet
requirements
and
restrictions of sodium

>
knowled
complia
regimen

> instruct client and

family on medications,
side
effects,
contraindications and
signs to report

Problem#6: Risk for Aspiration

Cues
S> O
O>

the

patient

Nursing
Diagnosis
Risk
Aspiration
presence

for
r/t
of

Scientific
Explanation

Objectives

Pneumonai
is
a
serious infection that
affects the airsacs

Short term:
After 4 hours of
NI, the patient

Nursing Interventions
>Establish rapport

>to
coope

manifested:
- with productive
cough
- with presence
of crackles on
lower lobe of the
right lung
- with
oxygen
hooked via nasal
cannula
regulated at 2
lpm
- with condom
catheter attached
to urine bag
continuous
cardiac
monitoring

retained
secretions

with accompanying
secretions that may
be expectorated.
Sudden
coughing
may mobilize the
secretions and may
reach the airway
which may cause
distress
to
the
patients
breathing
which is fatal. Usually
when
someone
aspirates they cough
in an attempt to clear
the food or fluid out
of their lungs.

will be free from

aspiration
AEB
having a patent
airway

>Assess patients condition

>Monitor VS

>to
data.
>
Monitor
consciousness

Long term:
After 2 days of
NI, the patient
will
experience
no
aspiration
AEB
noiseless
respirations and
clear
breath
sounds

>the patient may

manifest:
respiratory
distress

>to d
and s

level

of

> A de
consc
prime
aspira

>
Keep suction setup
available and use as needed
> Notify the physician or
other health care provider
immediately
of
noted
decrease in cough and/or
gag reflexes or difficulty in
swallowing
>Assist
drainage

with

> Ea
protect
airway
aspirat

postural

>Provide a rest period prior

to feeding time
>Minimize
use
sedatives/hypnotics
whenever possible.

> This
mainta
airway

of

>Provide information on the

effect of aspiration on the
lungs

>to mo
secreti
cause
swallow

>the re
have l
swallow

>these
impair
swallow

>sever
cyanos
with ea
or cha
quality
indicate
respira
associa
aspirat
immed
interve

>Refer

>to pro
of care

Problem#7: Anxiety
Cues

Nursing
Diagnosis

Scientific Explanation

Objectives

Nursing Interventions

S= O
O= pt. manifested
-with good skin
turgor
-with pale
palpebral
conjunctiva
-with capillary
refill 2 seconds
- Cold clammy
skin
-with oxygen
hooked via nasal
cannula regulated
at 2 lpm
-with condom
catheter attached
to urine bag
-continuous
cardiac
monitoring

Pt. may manifest:

-Sleep
disturbance
-Restlessness
-Tachycardia
-Tachypnea

Anxiety r/t
perceived
/actual threat of
death, pain,
possible lifestyle
changes by
restlessness

Coping with the pain and

emotional trauma is difficult.
Patient may fear death and or
be anxious about immediate
environment. Ongoing anxiety
(related to concerns about
impact of heart attack on
future lifestyle, matters left
unattended/unresolved and
effects of illness on family)
may be present in varying
degrees for some time and
maybe manifested by
symptoms of depression such
as sleep disturbance and
restlessness.

Short term:
After 3-4 hours
of nursing
intervention pt
will identify
healthy ways to
deal with and
express anxiety.

>Establish rapport
>Assess patients condition
>Monitor vital signs

>Observe for verbal/nonverbal signs of anxiety, and

stay with the pt. Intervene if
pt. displays destructive
behavior.
Long term:
After 3 days of
nursing
intervention pt.
will appear
relaxed and
report anxiety is
reduced to a
manageable
level.

>Maintain confident manner

(without false reassurance)
>Orient pt/SO to routine
procedures and expected
activities
>Provide privacy for pt. and
SO.

>Provide rest
periods/uninterrupted sleep,
quiet surroundings.
>Raise side rails
>Emphasize importance of
adequate nutritional intake.
>Regulate and monitor IV
fluid.
>Administer medications as
ordered

Problem#8: Fatigue
Nursing
Diagnosis

Cues
S > agad ako
napapagod, tulad pag
maglalakad
at
maliligo ako
O>
The
patient
manifests:
cold clammy skin
dry skin
weakness even with
simple activities
capillary refill < 3 sec.
crackles on the right
lung field
v/s
taken
and
recorded as follows:
T=36C, RR=21 cpm,
PR=65
bpm,
BP=130/80 mmHg.

The
patient
manifests:
restlessness
tachypnea

may

Fatigue
decrease
oxygenation
perfusion
pulmonary
congestion

Scientific
Explanation
r/t
and
2

Fatigue
is
an
overwhelming
sustained sense of
exhaustion
and
decreased capacity
for
physical and
mental work at usual
level.
Insulin
is
secreted by beta
cells, which are one
of four types of cells
in the islets of
Langerhans in the
pancreas, insulin is a
storage
hormone,
when a person eats
a
meal,
insulin
secretion increases
and move glucose to
the
blood,
into
muscle, liver, and fat
cells. Due to DM
type 2 there is insulin
resistance
or
impaired
insulin
secretion
which
results
in
the
inhibition
of
the
transport
and
metabolism
of
glucose into energy
leading
to
easy
fatigability AEB by pt.
weakness
even
doing activities of
daily living.

Objectives
Short term:
After 3 hours of
nursing
interventions
patient will be able
to perform ADLs
and participate in
desired activities at
level of ability.

Nursing Interventions
>Establish rapport

>to
an
of

>Assess
condition

>to
ge
sta
pa

patients

> Monitor vital signs

>to
ba
Long term:
After 1 day of
nursing
interventions
patient will report
improve sense of
energy.

> Instruct patient to

increase fluid intake up
to 8- 10 glasses of water
> Instruct to sit instead of
standing during activities
or shower
>Instruct
patient
to
increase
intake
of
vitamin
or
iron
supplementation
like
juice

>
en
to
de

>
en

>
ov
me

>Stretch linens
>Assist with self-care
needs like keep bed in
low position
>Stress
washing

proper

>Administer
ordered.

>to
co

hand

>T
en
drugs

as

>to
inf

>
we