Nursing Care Plan

I. Nursing Care Plan

Cues and Clues Nursing diagnosis

Scientific Rationale

Objective Nursing Interventions Rationale Evaluation

Objective Presence of

secretions in the mouth

With presence of wet cough and viscous secretions

Unable to cough properly

BP 180/90 Capillary

refill less than 2

Rapid breathing

Restlessness

Ineffective airway clearance

Medical management of the clients with coronary artery disease is directed at early diagnosis and identification of the client who can benefit from thrombolytic treatment. Preserving cerebral oxygenation, preventing complications and stroke recurrence, and rehabilitating the client are other goals.Emergency care of the client with stroke includes

After 1-3 hours of nursing intervention, the client will maintain patent airway

As evidence by:

After nursing interventions, the client’s airway patency will be assessed

The section will be readily expectorated

The client will be positioned comfortably with maximum lung expansion

Learn and perform coughing

Position the patient in high fowlers or semi- fowlers position if not contraindicated

Monitor vital signsAuscultate breath sounds. Note adventitious breath sounds, eg. Wheezes, crackles, rhonchi.Assess or monitor respiratory rate.

Suction secretions if present

Perform and teach proper coughing technique

To promote good lung expansion

Provide baseline for patient care

Patients who are immobile and unconscious have ineffective cough reflexes thus suctioning is required to remove secretions. Suction time should be minimized and hyperoxygenation performed to reduce the potential for hypoxia

To promote airway clearance and reduce straining that can

Objective Presence of

secretions in the mouth

With presence of wet cough and viscous secretions

Unable to cough properly

BP 180/90 Capillary refill

less than 2 Rapid

breathing Restlessness

maintaining a patient airway.

exercise properly

After 1-2 days of nursing interventions patient must be able to: Expectorate

secretions Able to

cough

Place patient in a comfortable position.

Advised patient to take 2-3 deep breaths through the nose and exhale. Hold the last break for at least 3 second when you inhale

Open the mouth slightly, place the hand on the abdomen and while gently pressing the diaphragm. The first cough should have moved the mucus to the throat.

Take a break and repeat as needed

increase ICP

Semi- fowler is recommended

Cues and Clues Nursing diagnosis

Scientific Rationale

Objective Nursing Interventions Rationale Evaluation

Objective Body

weakness Loss of

consciousness

Unable to communi-cate

Headache with seizures, clonic with upward rolling of eyeballs

BP 180/90 shallow and

in quantity Capillary

refill less than 2

Pale and cool to touch extremities

Fever Rapid

breathing Restlessness Nerve

Ineffective tissue perfusionA. CerebralB. PeripheralC. Respiratory

Atherrosclerosis affects the intima of the large and medium-seized arteries. These changes consist of the accumulation of lipids calcium, blood components, carbohydrates, and fibrous tissue on the intimal layer of the artery. These accumulations are referred to as plaques. The most common direct result is the narrowing of the lumen of the arteries and obstruction by thrombosisGradual narrowing of the arterial lumen

After 2-4 hours of nursing interventions patient must be able to: Breath

effectively Determine

the factors that causes ineffective cerebral tissue perfusion

Promote lung expansion

Blood pressure will decrease from 180/90- 120/80

After 6-10 hours of nursing interventions, patient must be able to Present no

signs of

A. Cerebral tissue perfusionMonitor/document neurological status frequently and compare with baseline

- GCS- Cranial nerves- Reflex

response- Motor and

sensory response

Keep client flat on back for several hours, per protocol.Monitor vital signs Note skin color and capillary refill

Monitor I &O

Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in determining location, extent, and progression/resolution of CNS damage.

Fluctuations in pressure may occur because of cerebral pressure/injury in vasomotor area of the brain. Hypertension may have been a precipitating factor. Hypotension may occur because of shock (circulatory collapse). Increased ICP may occur because of tissue edema or clot formation. bradycardia, can occur because of the brain damage.

Fluid balance indicates

Objective Body

weakness Loss of

consciousness

Unable to communi-cate

Headache with seizures, clonic with upward rolling of eyeballs

BP 180/90 shallow and

in quantity Capillary

refill less than 2

Pale and cool to touch extremities

Fever Rapid

breathing Restlessness Nerve

compression

compression stimulates the development of collateral circulation. Collateral floe allows continued perfusion to the tissues, but it is often inadequate to meet increased metabolic demand.

paleness and cool sensation of the extremities

Must be able to communicate effectively, decrease slurring of speech

weakness must lessened

Assess extremities- particularly lower extremities- for redness, swelling, and pain

Evaluate pupils, noting size, shape, equality, and light reactivity.

Document changes in vision such as-Reports of blurred vision, -alterations in visual-Field/depth perception.

Administer IV fluids

circulatory status and replacement needs. Excessive or prolonged blood loss requires evaluation and ongoing assessments to continually determine and provide prompt and appropriate intervention

Redness, swelling, and pain in the extremities suggest complications associated with immobility including DVT

Pupil reactions are regulated by the oculomotor (III) cranial nerve and are useful in determining whether the brainstem is intact.

Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence choice of interventions.

Fluid replacement depends on the degree of

Monitor CBC

(Hgb, hct)

B. Peripheral tissue perfusion

Inspect legs from groin to foot for skin color and temperature changes as well as edema

Assess capillary refill

Elevate legs when in bed, as needed

Perform ROM exercises

hypovolemia and duration of bleeding or leakage of CSF

These laboratory tests help establish fluid status and the need for fluid and blood replacement

Symptoms help distinguish between thrombophlebitis and DVT. Redness, heat, tenderness, and localized edema are characteristics of superficial involvement

Diminished capillary refill usually present in DVT

Reduces tissue swelling and rapidly empties superficial and tibial veins, preventing over distention and thereby increasing venous return

To maintain joint mobility, regain motor control; prevent

C. Respiratory

Elevate the head

Mechanical ventilator may be used if respiratory distress is present

Monitor laboratory studies as indicated, such as,-prothrombin time (PT)/activated partial-thromboplastin time (aPTT) timeCBCECGCT scanBlood chem.Urinalysis

contractures in the paralyzed extremity.And also to prevent venous stasis

To promote better lung expansion

To prevent respiratory distress/failure

Provides information about drug effectiveness/therapeutic level.

Cues and Clues Nursing diagnosis

Scientific Rationale

Objective Nursing Interventions Rationale Evaluation

Objective: Dx: acute

coronary syndrome, cardiac arrhythmia, ASHD, CAD, inferior wall ST segment elevation MI not in failure class IV-D, dyslipidemia, decrease effective circulating volume

Change in the rate, rhythm, and electrical conduction

Reduced preload

Increased SVR

Infarcted cardiac muscle

Decreased cardiac output related to decrease myocardial contractility

Decrease cardiac output occurs when there is a decrease in the contractility of myocardial muscles caused by an alteration in the blood supply to the coronary arteries

After less than an hour of nursing intervention, the patient will: Maintain

hemodynamic stability as evidenced by BP and cardiac output within normal range, adequate urinary output, decreased frequency and absence of ischemia.

Report decreased episodes of dyspnea, angina

After a week of nursing intervention, the patient will: Demonstrate

Auscultate BP. Compare both arms and obtain lying, sitting, and standing position when able.

Evaluate quality and equality of pulses, as indicated

Auscultate heart sounds.

Monitor heart rate and rhythm.

Note response to activity and promote rest appropriately.

Provide small/ easily digested meals as

Hypotension may occur related to hypoperfusion of the myocardium. Hypertension may also occur possibly related to pain, anxiety, or catecholamine release. Orthostatic hypotension may be associated with complications of infarct.

Decreased cardiac output results in diminished weak/thready pulses.

S4 sounds may be associated with myocardial ischemia.

Heart rate and rhythm respond to medication, activity, and developing complications.

Overexertion increases oxygen consumption/ demand and can compromise myocardial function.

Large meals may increase myocardial workload.

After less than an hour of nursing intervention, the patient was able to: Maintain

hemodynamic stability as evidenced by BP and cardiac output within normal range, adequate urinary output, decreased frequency and absence of ischemia.

Report decreased episodes of dyspnea, angina

After a week of nursing intervention, the patient was able to:Demonstrate an

an increase in activity tolerance

indicated

Administer supplemental oxygen, as indicated

Maintain IV/ Hep-Lock access as indicated

Review serial ECGs and laboratory data such as cardiac enzymes, ABGs, and electrolyte

Administer antidysrhythmic drugs as indicated

Increases amount of oxygen available for myocardial uptake, reducing ischemia and resultant cellular irritation.

Patent line is important for administration of emergency drugs in presence of persistent lethal dysrhythmias or chest pain

Provides information regarding progression/ resolution of infarction, status of ventricular function, electrolyte balance, and effects of drug therapies

To enhance ventricular output, increase survival and slow progression of MI

increase in activity tolerance

Cues and Clues Nursing Diagnosis

Scientific Rationale

Objectives Nursing Interventions Rationale Evaluation

Subjective: Reports of

chest pain which lasted for 30 minutes without any radiation to other body parts

Graded 3/10

Objective: Changes in

level of consciousness which lasted for an hour

Changes in pulse and BP(180/90)

Facial grimacing

Restlessness Moaning Crying Diaphoresis Clutching of

Acute pain related to tissue ischemia

The decrease in blood supply to the heart decreases the amount of oxygen and nutrients coming to the cardiac tissues. Cells begin to respire anaerobically and lactic acid is produced which causes pain.

After less than an hour of nursing intervention, the patient will: Verbalize

relief of chest pain

Display reduced tension, relaxed manner and ease of movement

Regain normalization of vital signs

Demonstrate use of relaxation techniques

After a week of nursing intervention, the patient will: Present no

signs of pain Adhere to

Obtain full description of pain from client including location, intensity, duration, characteristics, and radiation.

Monitor characteristic of pain, noting verbal reports, non-verbal cues

Instruct the client to report pain immediately.

Provide quiet environment, calm activities, and comfort measures

Assist in relaxation techniques such as

Pain is a subjective experience and must be described by the client to provide baseline for comparison to aid in the effectiveness of therapy

To determine the progress of the pain and to provide proper and appropriate interventions

Severe pain may induce shock by stimulating the SNS, thereby creating further damage and interfering with the diagnosis and relief of pain

Decreases external stimuli, which may aggravate anxiety and cardiac strain, limit coping abilities and adjustment to current situation

Provides a sense of having some control over

After less than an hour of nursing intervention, the patient was able to: Verbalize

absence of chest pain

Display reduced tension, relaxed manner and ease of movement

Heart rate and rhythm is sufficient to sustain adequate cardiac output/ tissue perfusion

Demonstrate use of relaxation techniques

After a week of nursing

chest Rapid

breathing

the therapeutic regimen provided

deep/slow breathing

Check vital signs before and after administration of narcotic medications

Administer supplemental oxygen by means of nasal cannula or face mask, as indicated

Administer medication as indicated:

Aspirin

Antianginals (nitroglycerin, ISDN, ISMN)

the situation

Hypotension/ respiratory depression can occur as a result of narcotic administration.

Increases amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia

Aspirin is the mainline medication to be given first to all acute MI clients. ASA posseses anti-inflammatory, analgesic, and antiplatelet qualities that assist in the stabilization of plaque while decreasing clotting potential.Nitrates are useful for pain control by coronary vasodilating effects, which increases coronary blood flow and myocardial perfusion. Peripheral vasodilation

intervention, the patient was able to: Present no

signs of painAdhere to the therapeutic regimen provided

Beta-blockers

Analgesics

effects reduce the volume of blood returning to the heart, thereby decreasing myocardial workload and demandSecond-line agents for pain control through effect of blocking sympathetic stimulationTo relieve the pain

Cues and Clues Nursing Diagnosis

Scientific Rationale

Objectives Nursing Interventions Rationale Evaluation

1 Episode of vomiting (5 cups)

Fatigue, Generalized Weakness

HypotensionPulse weak/threadTachycardia

DiarrheaUrine- Decreased, Concentrated Color, Oliguria

Report thirst, anorexia, nausea vomitingWeight lossMucous Membranes are drySkin dry with poor turgor, pale , moist, clammy

Restlessness

Risk for Fluid &

Electrolyte Imbalance related to vomiting

Extracellular fluid deficit leads to reduction in both the intracellular and extracellular fluid volumes which results to dehydration.

Sodium and Potassium as well, are the most common electrolytes affected by vomiting.Hypernatremia is the water loss relative to Na content due to inadequate amount of water in the body.Hypokalemia is an indirect result of the kidney compensating

After less than an hour of nursing intervention, the patient will:- have no epiasodes of vomiting and nausea-Remain safe from injury associated with electrolyte imbalance

After a week of nursing intervention, the patient will:-Present no signs and symptoms of Fluid & Electrolyte Imbalance-Adhere to the therapeutic regimen provided

Monitor VS and CVP. Observe for presence of fever.

Monitor laboratory studies

Administer IV solutions as indicated

Palpate peripheral pulses; Capillary refill, skin color/ temperature. Asses mental status.

Measure fluid losses from all sources (gastric losses, wound drainage, diaphoresis, urinary output)

Weigh daily and compare with 24-hr

Presence of tachycardia and hypotension is a cause of fluid deficit. CVP monitoring are useful in det. Degree of fluid deficit and response to replacement therapy. Fever increases metabolism and exacerbates fluid loss.

Electrolyte/ metabolic imablances may be present.

Fluid replacement therapy

Extracellular fluid deficit can result in inadequate organ perfusion to all areas

Fluid replacement needs are based on correction of current deficits and ongoing losses

Detect if there are any fluid losses. Third-space

After less than an hour of nursing intervention, the patient :-Had no occurrence of vomiting and nausea-Remained safe from injury associated with electrolyte imbalance

After a week of nursing intervention, the patient :-Was able to present no signs and symptoms of Fluid & Electrolyte Imbalance-Was able to adhere to the therapeutic regimen provided

ApathyConfusion

HypernatremiaHypokalemia

for the loss of acid.

fluid balance. Mark edematous areas.

Assess patient’s ability to swallow

Ascertain patient’s beverage preferences. Encourage foods with high fluid content

Provide skin and mouth care. Bathe every other day with mild soap. Apply lotion as indicated.

Monitor for reports of sudden chest pain, dyspnea, cyanosis, increased anxiety, restlessness

Monitor for sudden elevation of BP, restlessness, moist cough, dyspnea, crackles, frothy sputum

fluid accumulation cannot be used for tissue perfusion.

Impaired gag reflexes, anorexia, changes in LOC are factors that affect patient’s ability to replace fluids orally/

Relieves thirst and discomfort of dry mucous membranes. Augments parenteral replacement

Skin and mucous membranes are dry, w/ decreased elasticity, because of vasoconstriction and reduced intracellular water.

Hemo concentration and increased platelet aggregation may result in systemic emboli formation

May be a result of too rapid correction of fluid deficit compromising the cardiopulmonary system.

Cues and Clues Nursing Diagnosis

Scientific Rationale

Objectives Nursing Interventions Rationale Evaluation

Food intake less than recommended dietary allowance

Lack of interest in food

Misconceptions about diabetic diet

Body weight 20% under ideal

Diarrhea

Pale mucous membranes

Vomiting of 5 cups

Unable to take meals after vomiting episodes

Imbalanced nutrition: less than body requirements related to imbalance of insulin, food,and physical activity, vomiting,dietary restrictions

Neuropathy of the autonomic nervous system due to elevated blood glucose levels results to dysfunctions affecting theGI system, further resulting to delayed gastric emptying, which may occur with early satiety, bloating, nausea, and vomiting. In addition,there may be unexplained wide swings in blood glucoselevels related to inconsistent absorption of

After 4 hours of health teachings, the patient:

Explains in own words rationale fordietary restrictions and relationship tourea and creatinine levels

After the 8 hour shift, the patient:

Chooses foods within dietary restrictionsthat are appealing

Consumes high-calorie foods withindietary restrictions

Takes medications on schedule

Assess nutritional status:a. Weight changesb. Laboratory values (serum electrolyte,BUN, creatinine, protein, transferrin, blood glucose,and iron levels)

Assess patient’s nutritional dietarypatterns:a. Diet historyb. Food preferencesc. Calorie counts

Provide patient’s food preferenceswithin dietary restrictions

Alter schedule of medications so that theyare not given immediately before meals

Provide written lists of foods allowed and suggestions for

Baseline data allow for monitoring of changes and evaluating effectiveness of interventions.

Past and present dietary patterns areconsidered in planning meals

Increased dietary intake is encouraged.

Ingestion of medications just beforemeals may produce anorexia and feeling of fullness.

Lists provide a positive approach to dietaryrestrictions and a

After 8 hours, the patient consumed 100% of every plate of the recommended diabetic meal.The patient also took the necessary medications and self administered insulin in the last 24 hours.

the glucose fromingested foods secondary to the inconsistent gastric emptying, further resulting to intake of nutrients insufficient to meet metabolic needs.

After 24 hours, the patient:Consults written lists of acceptable foods

After 7 days, the patient:Reports increased appetite at meals

Demonstrates normal skin turgor withoutedema; healing and acceptable plasmaalbumin and glucose levels

After 30 days, the patient:Exhibits no rapid increases or decreases inweight

Encourage high-calorie, low-protein,low-sodium, and low-potassium

improving their taste without use of sodium or potassium.

Provide pleasant surroundings atmeal-times

Weigh patient daily.

Ensure that insulin orders are altered as needed for delays in eating.

Take insulin or oral antidiabetic agents as usual.

If vomiting, diarrhea, or fever persists, take liquids like 1⁄2 cuporange juice, 1⁄2 cup broth, 1 cup Gatorade every 1⁄2 to 1 hour.

Report nausea, vomiting, and diarrhea to the physician.

reference for patientand family to use when at home

Unpleasant factors that contribute topatient’s anorexia are eliminated

Allows monitoring of fluid and nutritionalstatus

Diagnostic and other procedures may interfere.

Normal values of blood glucose should be maintained as much as possible.

This prevents dehydration and helps to provide calories.

Extreme fluid loss may be dangerous and should be reported immediately.

snacksbetween meals Avoid delays in meal

timing.Do not skip meals.

Increase food intake before exercise if blood glucose level is<100 mg/dL.

Carry a form of fast-acting sugar at all times.

Maintains adequate glucose and energy in the body.

Hypoglycemia should be avoided.

In cases of hypoglycaemia, fast acting sugar could be taken.

Cues and Clues Nursing Diagnosis

Scientific Rationale

Objectives Nursing Interventions Rationale Evaluation

Presence of seizures described as clonic with upward rolling of eyeballs

Loss of consciousness lasting for an hour

Presence of bruises and injury

FatigueWeaknessExhaustionHeadache

NauseaPain

Memory lossConfusionDepression

Risk for Injury related to uncontrolled seizure activity

Seizures are disturbances in normal brain function resulting from abnormal electrical discharges in the brain, which can cause loss of consciousness, uncontrolled body movements, changes in behaviors and sensation, and changes in the autonomic system that may cause injury to themselves

After less than an hour of nursing intervention, the patient will:- No occurrence of seizure was present-No incidence of injury related to his seizure activity

After a week of nursing interventions, the patient will:-Have no incidence of injury related to his seizure activity-Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.

Explore with the patient the various stimuli that may precipitate seizure activity. Minimize stimuli that may cause seizure

Discuss seizure warning signs and usual seizure pattern

Keep padded side rails up with bed in lowest position

Evaluate need for protective head gear

Maintain strict bed rest if prodromal signs or aura is experienced.

Turn head to side or suction airway as indicated. Insert plastic bite block only if jaw are relaxed

Cradle head, place on

Lack of sleep, flashing lights, increase brain activity, hypertension may cause potential seizure activity

Enables the patient to protect self from injury

Minimizes injury

Use of helmet may provide added protection

Patient may feel restless to ambulate during aual phase, inadevertently removing self from safe environment and easy observation.

Maintain airway and reduces risk of oral trauma.

Gently guiding

soft area, or assist to floor if out of bed

Reorient patient following seizure activity

Administer medications as indicated

extremities reduces risk of physical injury when patient lacks voluntary muscle control

Patient may be confused, disoriented after seizure and need help to regain control and alleviate anxiety

Cues and Clues Nursing Diagnosis

Scientific Rationale

Objectives Nursing Interventions Rationale Evaluation

decrease in deep tendon reflexes

vibratory sensation

paresthesias

numb sensation of feet

decreased sensations ofpain and temperature

Risk for impaired skin integrity related to decreased effective circulating blood volume in the peripheral organs particularly the feet

Prolonged durations of elevated blood glucose levels lead to neuropathies of the peripherals further leading to alterations in the dermis and epidermis.

After 8 hours of the shift, the patient:

Participates in the prevention measures of ulcers and skin impairment.

Verbalize feelings of increased self esteem and ability manage situation.

After 7 days, the patient will be able to maintain good skin integrity.

After 30 days, patient will not develop skin lesions or ulcers.

Work with the health care team and relatives to keep the patient’s blood glucose level within a normal range.

Inspect the bare feet every day.

Use a mirror to check the bottoms of the feet or ask a family member for help.

Check for changes in temperature of the peripherals. Protect the feet from hot and cold

Wash the feet every day in warm, not hot, water.Dry the feet well. Be sure to dry between the toes. Do not soak feet.

Rub a thin coat of skin lotion over the tops and bottoms of the feet, but not between toes.

Collaborating with the different departments and family members helps in attaining the goal of maintaining the blood glucose of the patient.

Presence of cuts, blisters, red spots, and swelling could be detected early.

The patient may have trouble seeing and inspecting the feet.

Changes in temperature may indicate possible infections or necrosis.

Feet hygiene minimizes necrosis and infection.

Keeps the skin soft and smooth.

After hours, patient was able to verbalize understanding of the health teachings regarding skin care.Patient was able to do measures such as cleaning the peripherals especially the feet during the night, inspecting the feet, and covering it with fitting and comfortable socks.

Use a pumice stone to smooth corns and calluses.

Instruct to wear shoes and socks at all times and never walk barefoot.

Instruct to wear socks at night if the feet get cold.

Put the feet up when sitting.Wiggle the toes and move the ankles up and down for5 minutes, 2 or 3 times a day. Do not cross your legs for long periods of time.

Report if a cut, sore, blister, or acbruise on the foot does not begin to heal after one day.

This helps to smooth corns and calluses gently.

Provides protection to the feet.

Avoidance of temperature changes to the feet helps maintain good circulation.

These keep the blood flowing to the feet.

The patient may not feel the pain of an injury.