Nursing Care Plans for Cardiovascular Disease PDF

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Care plans for CAD and nursing interventions...

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eNursing Care Plan 33-1 Patient with Acute Coronary Syndrome Nursing Diagnosis* Impaired Cardiac Output Etiology: Altered contractility, altered heart rate and rhythm Supporting data: Decrease in BP, elevation in HR, dyspnea, dysrhythmias, diminished pulses, peripheral edema, pulmonary edema Patient Goal Maintains stable signs of effective cardiac output Outcomes (NOC) Tissue Perfusion: Cardiac  Angina ___  Dysrhythmia ___  Tachycardia ___  Bradycardia ___  Profuse diaphoresis ___  Nausea ___  Vomiting ___ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None

Interventions (NIC) and Rationales Cardiac Care: Acute  Monitor cardiac rhythm and rate and trends in BP and hemodynamic parameters to monitor for changes in cardiac output, BP, and heart rhythm, which may lead to coronary hypoperfusion.  Auscultate lungs for crackles or other adventitious sounds that can indicate pulmonary edema.  Monitor effectiveness of oxygen therapy (e.g., pulse oximetry) to determine O2 of myocardial tissue and prevent further ischemia.  Monitor serum cardiac biomarkers (troponin, CK-MB levels) to determine myocardial injury and recovery.  Monitor neurologic, renal, and liver function to evaluate blood perfusion to vital organs.

Nursing Diagnosis Acute Pain Etiology: Imbalance between myocardial O2 supply and demand Supporting data: Patient’s report of chest pain and tightness with radiation of pain to the neck and arms, increased cardiac biomarkers, ECG changes supporting ST-elevation MI Patient Goal Reports relief of pain Outcomes (NOC) Pain Control  Uses preventive measures ___  Uses analgesics

Interventions (NIC) and Rationales Cardiac Care  Evaluate chest pain (e.g., PQRST [see Table 33-7]) to accurately evaluate, treat, and prevent further ischemia.  Monitor vital signs frequently to determine baseline and

*Nursing diagnoses listed in order of priority. Copyright © 2020 by Elsevier, Inc. All rights reserved.

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33-2

Outcomes (NOC) appropriately ___  Reports uncontrolled symptoms to health care professional ___  Reports pain controlled _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated

Interventions (NIC) and Rationales detect ongoing changes.  Obtain 12-lead ECG during pain episode to help differentiate angina from extension of MI or pericarditis. Pain Management  Provide optimal pain relief with prescribed analgesics because pain exacerbates tachycardia and increases BP.  Consider the type and source of pain when selecting pain relief strategy because angina responds to opioids and measures that increase myocardial perfusion.

Nursing Diagnosis Anxiety Etiology: Perceived or actual threat of death, pain, possible lifestyle changes Supporting data: Restlessness, agitation, states concern over lifestyle changes and prognosis, such as patient’s statement, “What if I die? Everyone relies on me” Patient Goal Reports decreased anxiety and increased sense of self-control Outcomes (NOC) Anxiety Level  Restlessness ___  Verbalized apprehension ___  Difficulty concentrating ___  Distress ___ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None

Interventions (NIC) and Rationales Anxiety Reduction  Observe for verbal and nonverbal signs of anxiety to identify signs of stress and intervene appropriately.  Identify when level of anxiety changes because anxiety increases myocardial O2 consumption.  Use a calm, reassuring approach to avoid increasing patient’s anxiety.  Teach patient on the use of relaxation techniques (e.g., relaxation breathing, imagery) to enhance self-control and reduce anxiety.  Encourage caregiver(s) and family member(s) to stay with patient to provide comfort and support.  Encourage verbalization of feelings, perceptions, and fears to decrease anxiety and stress.  Provide factual information concerning diagnosis, treatment, and prognosis to decrease fear of the unknown.

Acceptance: Health Status  Coping Enhancement  Recognizes reality of health  Provide the patient with realistic choices about certain situation ___ aspects of care to support decision making.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

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Outcomes (NOC)  Adjusts to change in health status ___  Makes decisions about health ___

Interventions (NIC) and Rationales  Assist the patient in identifying positive strategies to deal with limitations and manage needed lifestyle or role changes.  Help the patient to grieve and work through the losses of chronic illness to provide support.

Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated

Nursing Diagnosis Activity Intolerance Etiology: General weakness due to decreased cardiac output and poor lung and tissue perfusion Supporting data: Patient’s report of fatigue with minimal activity, inability to care for self without dyspnea and/or increased heart rate Patient Goal Achieves a realistic program of activity that balances physical activity with energyconserving activities Outcomes (NOC) Activity Tolerance  O2 saturation with activity ___  Pulse rate with activity ___  Ease of breathing with activity ___  Walking pace _____  Ease of performing ADLs ___ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised

Interventions (NIC) and Rationales Cardiac Care  Monitor patient’s response to cardiac medications because these drugs often affect BP and pulse.  Encourage alternating activity and rest periods to avoid fatigue and to increase activity tolerance without rapidly increasing cardiac workload. Energy Management  Assist the patient to understand energy conservation principles (e.g., the requirement for restricted activity or bedrest) to conserve energy and promote healing.  Teach patient, caregiver(s), and family member(s) techniques of self-care that will minimize O2consumption (e.g., self-monitoring and pacing techniques for performance of ADLs) to promote independence and minimize O2 consumption.

Copyright © 2020 by Elsevier, Inc. All rights reserved.

eNursing Care Plan

33-4

Nursing Diagnosis Lack of Knowledge Etiology: Lack of knowledge of disease process, risk factor reduction, rehabilitation, home activities, and medications Supporting data: Questions about illness, management, and care after discharge Patient Goal Describes the disease process, measures to reduce risk factors, and rehabilitation activities necessary to manage the therapeutic regimen Outcomes (NOC) Knowledge: Cardiac Disease Management  Usual course of disease process ___  Signs and symptoms of worsening disease ___  Strategies to reduce risk factors ___  Importance of completing cardiac rehabilitation program ___  Benefits of following a low-fat, low-cholesterol diet ___  Benefits of regular exercise ___ Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge

Interventions (NIC) and Rationales Cardiac Care: Rehabilitative  Encourage realistic expectations for the patient, caregiver(s), and family member(s) to promote realistic decision making.  Teach patient, caregiver(s), and family member(s) about prescribed and over-the-counter drugs to promote compliance with drug regimens.  Teach the patient and caregiver about cardiac risk factor modification (e.g., smoking cessation, diet, exercise) to increase patient’s control of the illness.  Teach the patient self-care of chest pain (e.g., take sublingual nitroglycerin every 5 minutes three times; if chest pain unrelieved, seek emergency medical care).  Teach the patient and caregiver about the exercise regimen, including warm-up, endurance, and cooldown, to reduce cardiac risk factors.  Teach the patient and caregiver on wound care and precautions (e.g., sternal incision or catheterization site), if appropriate, to prevent infection and promote healing after invasive therapies.  Teach the patient and caregiver how to access emergency services available in their community to enable them to obtain immediate care if needed.

Copyright © 2020 by Elsevier, Inc. All rights reserved....