Assessment Subjective Data “I am experiencing heart palpitations since yesterday morning, I feel like my heart is going to pop out of my chest” as verbalized by the patient Objective Data HR- 145bpm BP-100/70mmHg Weak or diminished peripheral pulses Cyanosis in the extremities ECG changes Diagnosis Decreased cardiac output related to alteration in the heart rate and rhythm secondary to atrial fibrillation as evidenced by irregular HR 130-160bpm, BP 108/70mmHg and ECG result Planning Short term After 12-24 hours of nursing intervention the patient will report decreased episodes of heart palpitations and angina and avoid activities that increases cardiac workload. Long term After 4-7 days of nursing intervention Display vital signs within acceptable limits, dysrhythmias absent or controlled, and no symptoms of failure, for example, hemodynamic parameters within acceptable limits and Intervention INDEPENDENT Auscultate apical pulse; assess heart rate, rhythm, and document dysrhythmia if telemetry available. Rationale Tachycardia is usually present, even at rest, to compensate for decreased ventricular contractility. Premature atrial contractions (PACs), paroxysmal atrial tachycardia (PAT), PVCs, multifocal atrial tachycardia (MAT), and AF are common dysrhythmias associated with HF, although others may also occur. Note: Intractable ventricular dysrhythmias unresponsive to medication suggest ventricular aneurysm. Note heart sounds. S1 and S2 may be weak because of diminished pumping action. Gallop rhythms are common (S3 and S4), produced as blood flows into noncompliant, distended chambers. Murmurs may reflect valvular incompetence and stenosis Palpate peripheral pulses. Decreased cardiac output may be reflected in diminished radial, popliteal, dorsalis pedis, and post-tibial pulses. Pulses may be fleeting or irregular to palpation, and Evaluation The Goal was met, after 24 hours of nursing intervention the patient reported decreased episodes of heart palpitations and angina and recognized and avoided activities that increases cardiac workload After 7 days of nursing intervention the patient exhibited acceptable vital signs, dysrhythmias are reduced and absence symptoms of failure pulsus alternans may be present Cardiac dysrhythmias may occur from low perfusion, Assess the cardiac rate, acidosis, or hypoxia, as well rhythm, and electrocardiogram as from side effects of cardiac (ECG). medications used to treat this condition. The 12-lead ECG may provide evidence of myocardial ischemia (STsegment and T-wave changes) or pericardial tamponade (decreased voltage of QRS complex). Note changes in sensorium, for example, lethargy, confusion, disorientation, anxiety, and depression. Encourage rest, semi recumbent in bed or chair. Assist with physical care, as indicated. Provide quiet environment, explain medical and nursing management, help client avoid stressful situations, listen and respond to expressions of feelings or fears May indicate inadequate cerebral perfusion secondary to decreased cardiac output. Physical rest should be maintained during cardiac dysrhythmias to improve efficiency of cardiac contraction and to decrease myocardial oxygen consumption and workload. Physical and psychological rest helps reduce stress, which can produce vasoconstriction, elevating BP and increasing heart rate and work. Provide bedside commode. Have client avoid activities eliciting a vasovagal response, for instance, straining during defecation and holding breath during position change Check for calf tenderness; diminished pedal pulse; and swelling, local redness, or pallor of extremity. DEPENDENT Administer supplemental oxygen, as indicated. Administer medications, as indicated, for example: Commode use decreases work of getting to bathroom or struggling to use bedpan. Vasovagal maneuver causes vagal stimulation followed by rebound tachycardia, which further compromises cardiac function and output. Reduced cardiac output, venous pooling and stasis, and enforced bedrest increases risk of thrombophlebitis. Increases available oxygen for myocardial uptake to combat effects of hypoxia and ischemia. A variety of medications) may be used to increase stroke volume, improve contractility, and reduce congestion. Inotropics Dopamine Dopamine stimulates beta-1 adrenergic receptors, resulting in increased cardiac output and stimulates dopamine receptors, resulting in vasodilatation. Anticoagulants, such as lowdose heparin, and warfarin May be used prophylactically to prevent thrombus and (Coumadin); or antiplatelet agents, for example, low-dose aspirin, clopidogrel (Plavix), tirofiban (Aggrastat) embolus formation in the presence of risk factors, such as venous stasis, enforced bedrest, cardiac dysrhythmias, and history of previous thrombolic episodes. Measure cardiac output and other functional parameters, as indicated. Cardiac index, preload and afterload, contractility, and cardiac work can be measured noninvasively by using thoracic electrical bioimpedance (TEB) technique. TEB is useful in determining effectiveness of therapeutic interventions and response to activity. Assessment Subjective Data “ I feel pain in my chest even when doing a light household chores, I feel so weak and tired all the time and feel dizzy when standing up” as verbalized by the client Objective Data BP- 110/70 mmHg PR-101bpm Diagnosis Activity Intolerance related to imbalance between oxygen supply and demand secondary to dysrhythmias as evidenced by abnormal heart rate, dizziness, exertional discomfort, and generalized body weakness Planning Intervention Rationale Short term goal After 16-24 hours of nursing intervention the patient will be able to verbalize increase level of energy and reduce exertional discomfort during an activity Document cardiopulmonary response to activity. Note tachycardia, dysrhythmias, dyspnea, diaphoresis, and pallor. Compromised myocardium and inability to increase stroke volume during activity may cause an immediate increase in heart rate and oxygen demands, thereby aggravating weakness and fatigue Long term Goal After 4-6 days of nursing intervention the patient will be able to participate in desired activities; meet own self-care needs and will be able to achieve measurable increase in activity tolerance, evidenced by reduced fatigue and weakness and by vital signs within acceptable limits during activity Provide assistance with self-care activities, as indicated. Intersperse activity with rest periods. Meets client’s personal care needs without undue myocardial stress or excessive oxygen demand. Meets client’s personal care needs without undue myocardial stress or excessive oxygen demand. Sleep deprivation and difficulties during sleep can affect the activity level of the patient – these needs to be addressed before successful activity progression can be achieved. Have the patient perform the activity more slowly, in a longer time with more rest or pauses, or with assistance if necessary. Helps in increasing the tolerance for the activity. Gradually increase activity with active range-of-motion exercises in bed, increasing to sitting and then standing. Gradual progression of the activity prevents overexertion. Refrain from performing nonessential activities or procedures. Patient with limited activity tolerance need to prioritize important task first. Evaluation The Goal was met After 24 hours of nursing intervention the patient verbalized increased level of energy and reduce exertional discomfort during light activities After 6 days the patient participated and was able to execute desired activities, verbalized increased activity tolerance with the absence or reduced fatigue and weakness and the patient’s vital signs are within acceptable range during an activity Assist with ADLs while avoiding patient dependency. Assisting the patient with ADLs allows conservation of energy. Carefully balance provision of assistance; facilitating progressive endurance will ultimately enhance the patient’s activity tolerance and selfesteem. Encourage verbalization of feelings regarding limitations. This helps the patient to cope. Acknowledgment that living with activity intolerance is both physically and emotionally difficult. Encourage active ROM exercises. Encourage the patient to participate in planning activities that gradually build endurance. Exercise maintains muscle strength, joint ROM, and exercise tolerance. Teach energy conservation techniques, such as: Sitting to do tasks Frequent position changes Pushing rather than pulling Sliding rather than lifting Working at an even pace Placing frequently used items within easy reach Resting for at least 1 hour after meals before starting a new activity These techniques reduce oxygen consumption, allowing a more prolonged activity. Using wheeled carts for laundry, shopping, and cleaning needs Organizing a work-rest-work schedule Observe and document response to activity. Close monitoring will serve as a guide for optimal progression of activity. Assessment Subjective Data Patient states she has been extremely short of breath for the past 12 hours especially when doing household chores Objective Data oxygen saturation -85%, HR 112bpm BP 150/86mmHg RR 36cpm Use of accessory muscles Diagnosis Ineffective breathing pattern related to insufficient oxygen supply as evidenced by shortness of breath, use of accessory muscle, O2 sat85% Planning Intervention Short term goal INDEPENDENT After 24-72 hours the patient will maintain an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and reduced of dyspnea. Patient performs diaphragmatic pursed-lip breathing. Place patient with proper body alignment for maximum breathing pattern. Long term goal After 3-5 days of nursing intervention the patient will indicate, either verbally or through behavior, feeling comfortable when breathing. When patient carries out ADLs, breathing pattern remains normal. Rationale The goal was met A sitting position permits maximum lung excursion and chest expansion. Encourage sustained deep breaths by: These techniques promotes deep inspiration, which Using demonstration: increases oxygenation and highlighting slow inhalation, prevents atelectasis. Controlled holding end inspiration for a breathing methods may also aid few seconds, and passive slow respirations in patients exhalation who are tachypneic. Prolonged Utilizing incentive spirometer expiration prevents air Requiring the patient to yawn trapping. Encourage frequent rest periods and teach patient to pace activity. Extra activity can worsen shortness of breath. Ensure the patient rests between strenuous activities. Help patient with ADLs, as necessary This conserves energy and avoids overexertion and fatigue. Teach patient about: pursed-lip breathing abdominal breathing performing relaxation techniques performing relaxation techniques Evaluation These measures allow patient to participate in maintaining health status and improve ventilation. After 24 hours the patient performed pursed-lip breathing and demonstrated relaxed breathing at normal rate and depth and reduced dyspnea After 5 days of nursing intervention the patient verbalized the she can able to breathe comfortably and was able to carry out ADLs while breathing patterns remains normal taking prescribed medications (ensuring accuracy of dose and frequency and monitoring adverse effects) scheduling activities to avoid fatigue and provide for rest periods DEPENDENT Provide respiratory medications Beta-adrenergic agonist medications relax airway and oxygen, per doctor’s smooth muscles and cause orders. bronchodilation to open air passages. Assessment Subjective data “I suddenly feel nauseated when standing up in the morning after I wake up and chest pain when doing light household chores” as verbalized by the patient Objective Data PR-120bpm BP- 100/70mmHg Weak peripheral pulses Clammy skin Diagnosis Ineffective tissue perfusion related to impaired left ventricular filling, contractility or outflow obstruction secondary to premature ventricular contraction as evidenced by diminished peripheral pulses, elevated HR, clammy skin, Hypotension and nausea Planning Intervention SHORT TERM GOAL INDEPENDENT After 16-48 hours the patient will demonstrates adequate tissue perfusion as evidenced by palpable peripheral pulses, warm and dry skin, and the absence of chest pain When patient experiences dizziness due to orthostatic hypotension when getting up, educate methods to decrease dizziness, such as remaining seated for several minutes before standing, flexing feet upward several times while seated, rising slowly, sitting down immediately if feeling dizzy, and trying to have someone present when standing. LONG TERM GOAL After 2-3 days of nursing intervention the patient will be able to engage in behaviors or actions to enhance tissue perfusion and will display increasing tolerance to activity. Instruct the patient to avoid measures that may trigger increased ICP such as coughing, vomiting, straining at stool, neck in flexion, head flat, or bearing down. Rationale Evaluation The goal was met Orthostatic hypotension results in temporary decreased cerebral perfusion. After 48 hours of nursing intervention the patient demonstrated adequate tissue perfusion and reported absent of chest pain After 3 days of nursing intervention the patient was able to engage in activities that enhance tissue perfusion and reported increase tolerance to activity These will further reduce cerebral blood flow. Provide rest periods between care activities and prevent duration of procedures. Constant activity can further increase ICP by creating a cumulative stimulant effect. Assist with position changes. Gently repositioning patient from a supine to sitting/standing position can reduce the risk for orthostatic BP changes. Older patients are more susceptible to such drops of pressure with position changes. DEPENDENT Check for optimal fluid balance. Administer IV fluids as ordered. Sufficient fluid intake maintains adequate filling pressures and optimizes cardiac output needed for tissue perfusion. Administer medications as prescribed to treat underlying problem. Note the response. Peripheral vasodilators These enhance arterial dilation and improve peripheral blood flow. Inotropes These improve cardiac output. Provide oxygen therapy as necessary. This saturates circulating hemoglobin and augments the efficiency of blood that is reaching the ischemic tissues. Assessment Subjective Data “I am experiencing chest pain that radiates from my breast pain up to my jaw, I thought I’m just having heart burn but it got worse and also suffering from shortness of' breath on the littlest activity” as verbalized by the patient Objective Data Vital signs as follows HR 101bpm BP 180/100mmHg RR 22cpm Observes facial grimace Diaphoresis Diagnosis Acute pain related to reduced blood supply to the heart muscle secondary to atrial fibrillation which causes irregular heart beat as evidenced by abnormal HR, BP and verbalization of chest pain Planning After 12-24 hours of nursing intervention the patient will report that pain or discomfort is alleviated or controlled and will be able to verbalize methods that provide relief. Intervention Provide measures to relieve pain before it becomes severe. Rationale It is preferable to provide an analgesic before the onset of pain or before it becomes severe when a larger dose may be required. Instruct client to report pain immediately. Delays in reporting pain hinders pain relief and may necessitate increased dosage of medication to achieve relief. In addition, severe pain may induce shock by stimulating the sympathetic nervous system, thereby creating further damage and interfering with diagnostics and relief of pain. After 2-3 days of nursing intervention the patient will display relaxed manner; be able to sleep or rest and engage in desired activity. Assist or instruct in relaxation techniques, such as deep, slow breathing and distraction. DEPENDENT Administer supplemental oxygen by appropriate route Administer medications, as indicated; for example: Helpful in decreasing perception of or response to pain. Pro vides a sense of having some control over the situation, increase in positive attitude. Increases amount of oxygen available for myocardial uptake and thereby may relieve discomfort associated with tissue ischemia. Nitrates are useful for pain control by coronary vasodilating effects, which Evaluation The goal was met After 24 hours of nursing intervention the patient verbalized relief and was able to verbalize methods that provides relief After3 days the patient was able to do ADLs in a relax manner and was able to engage in desired activities with the absence of chest pain Anti-anginals, such as nitroglycerin (Nitro-Bid, Nitrostat, Nitro-Dur), isosorbide dinitrate (Isordil), and mononitrate (Imdur) increase coronary blood flow and myocardial perfusion. Peripheral vasodilation effects reduce the volume of blood returning to the heart (preload), thereby decreasing myocardial workload and oxygen demand Analgesics, such as morphine sulfate Although intravenous (IV) morphine is the usual drug of choice, other injectable opioids may be used in acutephase or recurrent chest pain (unrelieved by nitroglycerin) to reduce severe pain, provide sedation, and decrease myocardial workload. IM injections should be avoided, if possible, because they can alter the CPK diagnostic indicator and are not well absorbed in under perfused tissue.