Critical Care Clinical Nursing Care Plan

Critical Care Clinical Nursing Care Plan Critical Care Clinical Nursing Care Plan Overview Coronary artery disease (CAD) is a type of blood vessel disease associated with atherosclerosis. Inflammation and endothelial injury play a central role in the development of atherosclerosis. Once endothelial injury has occurred, lipoproteins (carrier proteins within the bloodstream) transport cholesterol and other lipids into the arterial intima. Over time, the deposition of cholesterol and lipids causes the formation of fibrous plaque, resulting in narrowing of the vessel lumen and a reduction in coronary artery blood flow. The final stage of plaque development results in a complicated lesion that can rupture, attract platelets, and cause the formation of a thrombus. The thrombus may adhere to the wall of the artery, leading to further narrowing or total occlusion of the artery. CAD develops slowly over many years and clinical manifestations are not apparent in the early stages of the disease process. However, there are associated risk factors that can identify persons at risk for CAD. Interventions can then be prescribed to modify these risk factors and reduce the onset and progression of the disease. NURS 411 Bowie Start University Critical Care Clinical Nursing Care Plan Chronic stable angina, a clinical manifestation of CAD, refers to chest pain that occurs intermittently over a long period with the same pattern of onset, duration, and intensity of symptoms. It is transient (reversible) chest pain that occurs when the heart muscle becomes ischemic during exertion or increased cardiac activity. It subsides when the precipitating factor is relieved and/or when nitroglycerin is provided and no permanent injury to cardiac cells occurs. Critical Care Clinical Nursing Care Plan When ischemia is prolonged and not immediately reversible, acute coronary syndrome (ACS) develops and includes the spectrum of unstable angina (UA), non-ST-segment-elevation myocardial infarction (NSTEMI), and ST-segment-elevation myocardial infarction (STEMI). The patient presenting with unstable angina is at high risk for developing an MI and thus must be treated aggressively. Myocardial infarction occurs as a result of sustained ischemia, causing irreversible cell death (necrosis) of the myocardium. Contractile function of the heart stops in the areas of myocardial necrosis, and the degree of altered function depends on the area of the heart involved and the size of the infarction. Objectives Identify relevant assessment data for a patient with ACS. Evaluate results of diagnostic studies for a patient with ACS. Prioritize nursing interventions for a patient with acute chest pain. Develop a nursing care plan for a patient with ACS. Describe the appropriate treatment for a patient with complications of ACS. Formulate an individualized teaching plan for a patient with ACS. Case Study G.G. is a 62-year-old white male with a 15-year history of coronary artery disease and hypertension. He had an anterolateral MI 2 years ago. He also has a history of hyperlipidemia, type 2 diabetes mellitus, and chronic renal insufficiency. His father died of sudden cardiac death at age 44, and his mother died while undergoing a coronary artery bypass graft (CABG) at age 68. His hypertension is treated with hydrochlorothiazide and verapamil (Calan), and he takes glyburide (DiaBeta) for control of his diabetes and lovastatin (Mevacor) for his high cholesterol. He is a current cigarette smoker with a 45 pack-year smoking history and drinks a beer almost daily. He is 5’10” tall, weighs 229 pounds, and does not regularly exercise. He tries to watch what he eats, but he travels a lot as a computer consultant and it is difficult to maintain a healthy, diabetic diet when he is out of town. Case Study Consult with the Expert View Animatio nursing_care_plans.pdf.pdf ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS 833 Chapter 34 Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome Patient with Acute Coronary Syndrome NURSING DIAGNOSIS PATIENT GOAL Acute pain related to myocardial ischemia as evidenced by severe chest pain and tightness, radiation of pain to the neck and arms Reports relief of pain OUTCOMES (NOC) INTERVENTIONS (NIC) and RATIONALES Pain Level Cardiac Care: Acute • Reported pain ____ • Evaluate chest pain (e.g., intensity, location, radiation, duration, and precipitating and al- Measurement Scale • Monitor effectiveness of oxygen therapy to increase oxygenation of myocardial tissue leviating factors) in order to accurately evaluate, treat, and prevent further ischemia. 1 Severe 2 Substantial 3 Moderate 4 Mild 5 None and prevent further ischemia. • Administer medications to relieve/prevent pain and ischemia to decrease anxiety and cardiac workload. • Obtain 12-lead ECG during pain episode to help differentiate angina from extension of MI or pericarditis. Pain Control • Monitor cardiac rhythm and rate and trends in blood pressure and hemodynamic parameters (e.g., central venous pressure and pulmonary artery wedge pressure) to monitor for hypotension and bradycardia, which may lead to hypoperfusion. sh is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m • Uses preventive measures ____ • Uses analgesics 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 NURSING DIAGNOSIS PATIENT GOAL Ineffective tissue perfusion (cardiac) related to myocardial injury and potential pulmonary congestion as evidenced by decrease in BP, dyspnea, dysrhythmias, peripheral edema, and oliguria Maintains stable signs of effective cardiac perfusion OUTCOMES (NOC) INTERVENTIONS (NIC) and RATIONALES Cardiac Pump Effectiveness Cardiac Care • • • • • Monitor vital signs frequently to determine baseline and ongoing changes. • Monitor for cardiac dysrhythmias, including disturbances of both rhythm and conduc- Systolic blood pressure ____ Diastolic blood pressure ____ Apical heart rate ____ Urinary output ____ tion, to identify and treat significant dysrhythmias. • Monitor respiratory status for symptoms of heart failure to maintain appropriate levels of oxygenation and observe for signs of pulmonary edema. Measurement Scale Th 1 Severely compromised 2 Substantially compromised 3 Moderately compromised 4 Mildly compromised 5 Not compromised • Monitor fluid balance (e.g., intake/output, daily weight) to monitor renal perfusion and observe for fluid retention. • Arrange exercise and rest periods to avoid fatigue and decrease the oxygen demand on myocardium. • Peripheral edema ____ • Dyspnea ____ • Dysrhythmia ____ Measurement Scale 1 Severe 2 Substantial 3 Moderate 4 Mild 5 None Continued Cardiovascular System NURSING CARE PLAN 34-1 Section 7 Problems of Oxygenation: Perfusion NURSING CARE PLAN 34-1—cont’d Patient with Acute Coronary Syndrome—cont’d NURSING DIAGNOSIS PATIENT GOAL Anxiety related to perceived or actual threat of death, pain, possible lifestyle changes as evidenced by restlessness, agitation, and verbalization of concern over lifestyle changes and prognosis as substantiated by patient’s statement of “What is going to happen when I die … everyone relies on me” Reports decreased anxiety and increased sense of self-control OUTCOMES (NOC) INTERVENTIONS (NIC) and RATIONALES Anxiety Self-Control Anxiety Reduction • • • • • • • • Monitors intensity of anxiety ____ Seeks information to reduce anxiety ____ Controls anxiety response ____ Uses relaxation techniques to reduce anxiety ____ . NURS 411 Bowie Start University Critical Care Clinical Nursing Care Plan • Measurement Scale 1 Never demonstrated 2 Rarely demonstrated 3 Sometimes demonstrated 4 Often demonstrated 5 Consistently demonstrated sh is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m NURSING DIAGNOSIS PATIENT GOAL • Observe for verbal and nonverbal signs of anxiety. Identify when level of anxiety changes since anxiety increases the need for oxygen. Use a calm, reassuring approach so as not to increase patient’s anxiety. Instruct patient in use of relaxation techniques (e.g., relaxation breathing, imagery) to enhance self-control. Encourage family to stay with patient to provide comfort. 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. Activity intolerance related to fatigue secondary to decreased cardiac output and poor lung and tissue perfusion as evidenced by fatigue with minimal activity, inability to care for self without dyspnea, and increased heart rate Achieves a realistic program of activity that balances physical activity with energy-conserving activities OUTCOMES (NOC) INTERVENTIONS (NIC) and RATIONALES Energy Conservation Cardiac Care • Balances activity and rest ____ • Recognizes energy limitations ____ • Uses energy conservation techniques ____ • Monitor patient’s response to antiarrhythmic medications since these medications will affect BP and pulse prior to activity. • Arrange exercise and rest periods to avoid fatigue and to increase activity tolerance without rapidly increasing cardiac workload. Measurement Scale 1 Never demonstrated 2 Rarely demonstrated 3 Sometimes demonstrated 4 Often demonstrated 5 Consistently demonstrated Energy Management • Assist patient to understand energy conservation principles (e.g., the requirement for restricted activity) to conserve energy and promote healing. • Teach patient and significant other techniques of self-care that will minimize oxygen Activity Tolerance consumption (e.g., self-monitoring and pacing techniques for performance of activities of daily living) to promote independence as well as minimize O2 consumption. • Oxygen saturation with activity ____ • Pulse rate with activity ____ • Ease of breathing with activity ____ Measurement Scale 1 Severely compromised 2 Substantially compromised 3 Moderately compromised 4 Mildly compromised 5 Not compromised Th Cardiovascular System 834 Adhering to a regular, individualized program of physical activity that conditions the heart rather than overstresses the myocardium is important. Most patients can be advised to walk briskly on a flat surface at least 30 minutes a day, 5 or more days a week.8 It is important to teach the patient and the family in the proper use of nitroglycerin (see pp. 000). Nitroglycerin tablets or ointments may be used prophylactically before an emotionally stressful situation, sexual intercourse, or physical exertion (e.g., climbing a long flight of stairs). Counseling should be provided to assess the psychologic adjustment of the patient and the family to the diagnosis of CAD and the resulting angina. Many patients feel a threat to their identity and self-esteem and may be unable to fill their usual roles in society. These emotions are normal and real. ? Nursing Implementation ? Acute Coronary Syndrome Acute Intervention. Priorities for nursing interventions in the initial phase of ACS include pain assessment and relief, physiologic monitoring, promotion of rest and comfort, alleviation of stress and anxiety, and understanding of the patient’s emotional Chapter 34 Nursing Management: Coronary Artery Disease and Acute Coronary Syndrome 835 Patient with Acute Coronary Syndrome—cont’d NURSING DIAGNOSIS PATIENT GOAL Ineffective therapeutic regimen management related to lack of knowledge of risk factors, disease process, rehabilitation, home activities, and medications as evidenced by frequent questioning about illness, management, and care after discharge Describes risk factors, the disease process, and rehabilitation activities necessary to manage the therapeutic regimen OUTCOMES (NOC) INTERVENTIONS (NIC) and RATIONALES Knowledge: Cardiac Disease Management Teaching: Disease Process • Description of usual course of disease • • • • • tain information on patient’s teaching needs. NURS 411 Bowie Start University Critical Care Clinical Nursing Care Plan • Explain the pathophysiology of the disease and how it relates to anatomy and physiology to individualize the information and to increase understanding. • Discuss lifestyle changes that may be required to prevent further complications and/or control disease process to get the cooperation of the patient’s significant support system. • Refer the patient to local community agencies/support groups so that the patient and family have resources and support available. sh is ar stu ed d vi y re aC s o ou urc rs e eH w er as o. co m • process ____ Description of symptoms of worsening disease ____ Description of ways to manage controllable risk factors ____ Description of importance of completing recommended cardiac rehabilitation program ____ Description of energy conservation techniques ____ Description of effects of medications ____ Description of options in assistance with medical emergencies ____ • Appraise the patient’s current level of knowledge related to myocardial infarction to ob- Teaching: Prescribed Medication • Instruct the patient on the purpose and action of each medication. • Instruct the patient on the dosage, route, and duration of each medication so that patient understands the reason for taking the medication and will be less likely to refuse to take medications. Measurement Scale 1 None 2 Limited 3 Moderate 4 Substantial 5 Extensive Th and behavioral reactions. Research has shown that patients with increased anxiety levels have a greater risk for adverse outcomes such as recurrent ischemic events and dysrhythmias.48 Proper management of these priorities decreases the oxygen needs of a compromised myocardium and reduces the risk of complications. In addition, the nurse should institute measures to avoid the hazards of immobility while encouraging rest. Pain. Nitroglycerin, morphine sulfate, and supplemental oxygen should be provided as needed to eliminate or reduce chest pain. Ongoing evaluation and documentation of the effectiveness of the interventions is important. Once pain is relieved, the nurse may have to deal with denial in a patient who interprets the absence of pain as an absence of cardiac disease. Monitoring. A patient has continuous ECG monitoring while in the ED and intensive care unit and usually after transfer to a stepdown or general unit. The nurse should be educated in ECG interpretation so that dysrhythmias causing further deterioration of the cardiovascular status can be identified and treated. During the initial period after MI, ventricular fibrillation is the most common lethal dysrhythmia. In many patients, this dysrhythmia is preceded by premature ventricular contractions or ventricular tachycardia. The nurse should also monitor the patient for the presence of silent ischemia by monitoring the S-T segment for shifts above or below the baseline of the ECG. Silent ischemia occurs without clinical symptoms such as chest pain, but its presence places a patient at higher risk for adverse outcomes and even death.48 If episodes of silent ischemia are seen on the monitor, the physician should be notified. (See Chapter 36 for a complete discussion of ECG monitoring.) Powered by TCPDF ( In addition to frequent vital signs, intake and output should be evaluated at least once a shift, and physical assessment should be carried out to detect deviations from the patient’s baseline parameters. Included is an assessment of lung sounds and heart sounds and inspection for evidence of early HF (e.g., dyspnea, tachycardia, pulmonary congestion, distended neck veins). Assessment of the patient’s oxygenation status is important, especially if the patient is receiving oxygen. Also, the nares should be checked for irritation or dryness, which can cause considerable discomfort if the nasal route is used for oxygen administration. Rest and Comfort. With a severe insult to the myocardium, as in the case of ACS, it is important for the nurse to promote rest and comfort. Bed rest may be ordered for the first few days after an MI involving a large portion of the ventricle. A patient with an uncomplicated MI (e.g., angina resolved, no signs of complications) may rest in a chair within 8 to 12 hours after the event. The use of a commode or bedpan is based on patient preference. When sleeping or resting, the body requires less work from the heart than it does when active. It is important to plan nursing and therapeutic actions to ensure adequate rest periods free from interruption. Comfort measures that can promote rest include frequent oral care, adequate warmth, a quiet atmosphere, use of relaxation therapy (e.g., guided imagery), and assurance that personnel are nearby and responsive to the patient’s needs. It is important that the patient understand the reasons why activity is limited. However, in spite of this limitation, the patient is not completely restricted. Gradually the cardiac workload is increased through more demanding physical tasks so that the patient Cardiovascular System NURSING CARE PLAN 34-1—cont’d … NURS 411 Bowie Start University Critical Care Clinical Nursing Care Plan Purchase answer to see full attachment Student has agreed that all tutoring, explanations, and answers provided by the tutor will be used to help in the learning process and in accordance with Studypool’s honor code & terms of service . Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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