Name: Mr. Heartbreaker Age: 52 years old Ward: Andrew Hall 1Chief Complaint: abdominal pain Diagnosis: Aortic Stenosis, Cardiomegaly, CHF III, Acute Kidney Injury secondary to Ischemic Nephropathy with Complicated UTI

CUES NURSING DIAGNOSIS

SCIENTIFIC RATIONALE

EXPECTED OUTCOME

NURSING INTERVENTIONS

RATIONALE EVALUATION

SUBJECTIVE:“Nadudu-as daw it akon im-im yakan nira ngan it akon kulo nagbuburusag gihap” as verbalized by the patient.

“Danay tigda la nalipong nak ulo labi na kun nabuhat ako” as verbalized by the patient.

“Nagkukuri gihap ako pagginhawa” as verbalized by the patient

OBJECTIVES:

V/S taken as follows: T= 36.1 ˚C RR= 31cpm HR= 60bpm BP= 140/70 mm

Hg Decrease

hemoglobin count (115g/dL)N=142-175g/dL

Pallor Pale nail beds Pale lips Shortness in

breath Chest pain

Ineffective tissue perfusion related to

vasoconstriction secondary to

redistribution of cardiac output to vital

organs

Vasoconstriction mediated by the sympathetic nervous system is largely responsible for the redistribution of cardiac output which serves as an important compensatory mechanism when flow is reduced. This redistribution is most marked when a patient with heart failure exercises or when an additional burdened is imposed, such as fever or anemia, but as heart failure advances, redistribution occurs even in the basal state. Blood flow is redistributed so that the delivery of oxygen to vital organs, such as the brain and myocardium, is maintained at normal or near normal levels, while flow to less critical areas, such as cutaneous and muscular beds and splanchnic viscera which results to ineffective perfusion to these areas.

SHORT TERM:

After 6 hours of nursing intervention, the patient will be able to maintain hemodynamic stability as evidenced by: Decrease blood

pressure and warm skin

Minimize report of chest pain

Normal capillary refill

Skin, palpebral conjunctiva, nasal mucosa, lips, oral mucosa and gums of natural pale, pink color

Absence or alleviation of lightheadedness

LONG TERM:

After 1 week of nursing intervention, the patient will be able to demonstrate increase tissue perfusion as evidenced by: No signs of pallor Able to perform

ADL’s without difficulty and dyspnea.

1. Assess general condition of the patient.

2. Assess vital signs.

3. Assess skin for coolness, pallor.

4. Provide a warm environment.

5. Perform capillary refill test.

6. Monitor urine output.

7. Encourage quiet, restful atmosphere.

8. Encourage active range of motion but provide rest periods.

9. Elevate bed at night.

COLLABORATIVE10. Administer

medications as prescribed:

Isoket (isosorbide

1. To assess the current status of client’s condition.

2. To obtain baseline data.

3. May indicate hypoxemia.

4. A warm environment promotes vasodilation, which decreases preload and tissue perfusion.

5. To check the adequacy of blood flow or circulation.

6. Decreased perfusion to the kidneys may result in oliguria.

7. Conserves energy and lowers tissue O2 demand.

8. Range of motion helps decrease venous pooling and promotes tissue perfusion.

9. To increase gravitational blood flow.

>Promotes peripheral

Goals partially met

After nursing interventions, the client had: Decreased blood

pressure with warm skin

Minimized report of chest pain

Capillary refill normal

Normal skin,palpebral conjunctiva, nasal mucosa, lips, oral mucosa and gum color

Absence of lightheadedness

Absence of pallor

Was able to perform some of his ADL’s like self care with less difficulty

Patient’s hematologic result slightly increased.

Delayed capillary refill (4 seconds)N-

Body malaise and activity intolerance

Fatigue Abnormal ABG

result (pH=7.530 N=7.350-7.450; pCO2=19.3mmHg N=35-45; pO2=113mmHg N=80-100)

Additional Diagnosis: Acute kidney injury secondary to ischemic nephropathy secondary to CHF, complicated UTI

Final diagnosis: severe aortic stenosis, cardiomegaly, CHF III ascites

Focus on Pathophysiology page 476 by Barbara L. Bullock and Reet L. Henze

Patient’s hematologic laboratory results will be normal or at least increase in value

dinitrate) 20mg 1 tab OD

Simvastatin(antihyperlipidemic) 20mg 1 tab OD

Bisoprolol (antihypertensive) 5mg ½ tab BID

11. Monitor ABG.

12. Oxygen administration as prescribed.

vasodilation and reduces preload and afterload, decreasing myocardial oxygen consumption and increasing cardiac output. Also dilates coronary arteries, increasing blood flow and improving collateral circulation

>Inhibits the enzyme that catalyzes the first step in the cholesterol synthesis pathway, resulting in decrease in serum cholesterol, and serum LDL’s.

>Decreases the excitability of the heart, thus decreasing the cardiac output and oxygen consumption, decreasing the release of rennin from the kidney, and lowering the BP.

11. Identifies hypoxemia, effectiveness or need for therapy.

12. To promote adequate tissue perfusion.