30764524-“acute-coronary-syndrome-non-st-elevation-myocardial-infarction-hypertensive-cardiovascular-disease-diabetes-mellitus-type-2-and-community-acquired...

8/13/2019 30764524-Acute-Coronary-Syndrome-Non-ST-Elevation-Myocardial-Infarction-Hypertensive-Cardiovascular-Disease-Diabetes-Mellitus-Type-2-and-Community-Acquired

1/21


2/21

aci# pro#uctioncausing irritation tot%e %eart (uscle&'%is (ec%anis(causes a feeling of

pain +%ic% (a$activate t%es$(pat%etic nervouss$ste( t%us causingtac%$pnea an#tac%$car#ia as aresponse& Due to t%eunco(fortablesensation! t%epatient (a$ be seen+it% facial gri(acesan# irritabilit$&

>.rovi#e a#e/uaterest perio#s

>Maintain be# rest

#uring pain! +it%position of co(fort!(aintain relaxingenviron(ent topro(ote cal(ness&

>.repare for t%ea#(inistration of(e#ications! an#(onitor response to#rug t%erap$& Notif$

p%$sician if pain#oes not abate&

>Revie+ +a$s tolessen pain

>.rovi#e forin#ivi#uali"e#p%$sicalt%erap$5exerciseprogra(s t%at can

be continue# b$ t%eclient +%en#isc%arge#

>Discuss +it% SO6s7+a$s in +%ic% t%e$can assist client an#re#uce precipitatingfactors t%at (a$cause or increasepain

>to prevent fatiguean# pro(oterelaxation

>to re#uce ox$genconsu(ption an##e(an#! to re#uceco(peting sti(ulian# re#ucesanxiet$

>pain control is apriorit$! as itin#icates isc%e(ia

>to pro(ote+ellness

>pro(otes active!not passive role

>to pro(ote+ellness

135


3/21

>Instructpatient5fa(il$ in(e#ication effects!si#e*effects!contrain#ications

an# s$(pto(s toreport

> to pro(ote

kno+le#ge an#co(pliance +it%t%erapeutic regi(enan# to alleviate fearof unkno+n

Problem#2: Ineffective airway clearance

Cues Nursing DiagnosisScientific

ExplanationObjectives

NursingInterventions

Rationale Evaluation

S> '%e patient (a$

verbali"e)* #$spnea

O> '%e patient(anifeste#)* pro#uctive coug%* fu""iness of t%elung (arkings inbot% lungs* +it% ox$gen%ooke# via nasalcannula regulate# at, lp(* +it% con#o(cat%eter attac%e# tourine bag* continuous car#iac(onitoring

> '%e patient (a$(anifest)* c%anges inrespirator$ rate orr%$t%(

Ineffective air+a$

clearance r5tretaine#trac%eobronc%ialsecretions -E0presence ofpro#uctive coug%

.neu(onia is an

infectious #iseasec%aracteri"e# b$infla((ator$processes affectingt%e lungparenc%$(a& '%einva#ing organis(causes s$(pto(s! inpart! b$ provoking anoverl$ exuberanti((une response int%e lungs&Mucus pro#uction isincrease# +%ic%plugs t%e air+a$t%us furt%erco(pro(ising t%eair+a$ clearance oft%e patient& '%isevent (a$ bringabout c$anosis& Inor#er toco(pensate! t%epatient (a$ breat%e

S%ort ter()

-fter 1 %ours of NI!t%e patient +ill#e(onstratebe%aviors to i(proveor (aintain air+a$patenc$&

2ong ter()-fter 1 #a$s of NI!t%e patient +ill#e(onstrateabsence5re#uction ofcongestion +it%breat% soun#s clear!respirationsnoiseless an#i(prove# ox$genexc%ange&

>Establis% rapport

>-ssess patient3scon#ition

>Monitor 4S

>-uscultate breat%soun#s

>-ssess respirator$(ove(ents an# useof accessor$(uscles

>Observe for signsan# s$(pto(s ofinfection

>to gain trust an#

cooperation

>to #eter(ine s5sx

>to obtain baseline#ata

> to note presenceof a#ventitiousbreat% soun#s

> use of accessor$(uscles to breat%ein#icates an#abnor(al increasein +ork ofbreat%ing

> to i#entif$infectious processan# pro(ote ti(el$interventions

S%ort ter()

-fter 1 %ours of NI!t%e patient s%all%ave verbali"e#(et%o#s t%atprovi#e relief&

2ong ter()-fter , #a$s of NI!t%e patient s%all%ave#e(onstrate# useof relaxationtec%ni/ues an##ivertionalactivities asin#icate# forin#ivi#ualsituation&

136


4/21

* #i(inis%e# ora#ventitious breat%soun#s* c$anosis

rapi#l$ in or#er tobring in (ore ox$gent%us (anifestingc%anges inrespirator$ rate or

r%$t%(&

>Monitor c%estra#iograp% reports

>8se positioning b$

placing on a se(i*%ig% fo+ler3s position

>Elevate %ea# ofbe# or c%angeposition ever$ ,%ours an# prn

>Maintain a#e/uate%$#ration +%enpossible

> .erfor(nebuli"ation an#C.' as in#icate#

>Institute suctioningas nee#e#

>8se naso*p%ar$ngeal 5 oro*p%ar$ngeal air+a$as nee#e#

>-#(inister(e#ication asprescribe#

>to (onitor t%eseverit$ of t%e#isease

>to facilitate lung

expansion

> to takea#vantage ofgravit$ #ecreasingpressure on t%e#iap%rag( an#en%ancing#rainage orventilation to#ifferent lung

seg(ents

>to ai# in t%e(obili"ation ofsecretions

>to loosensecretions

> to clear air+a$+%en secretions

are blocking t%eair+a$

> to %ave patentair+a$ t%roug%artificial (eans

>to provi#ep%ar(acological(anage(ent totreat con#ition

137


5/21

>-#(inisteranalgesics asprescribe#

>Refer toappropriate supportgroups

>to (axi(i"ecoug% +%en pain isin%ibiting effort

> to pro(otecontinuit$ of care

Problem#3: Impaire !as "c$ange





S> '%e patient (a$

verbali"e)* #$spnea

O> '%e patient(anifeste#)* pro#uctive coug%* fu""iness of t%elung (arkings inbot% lungs* +it% ox$gen%ooke# via nasalcannula regulate# at, lp(* +it% con#o(cat%eter attac%e# tourine bag* continuous car#iac(onitoring

> '%e patient (a$(anifest)* confusion* let%arg$* abnor(al -093s

I(paire# 9as

Exc%ange r5tcollection ofsecretions affectingox$gen exc%angeacross alveolar(e(brane

.neu(onia bot%

affects ventilationan# #iffusion& -ninfla((ator$reaction can occur int%e alveoli!pro#ucing exu#atest%at interfere in t%e#iffusion of ox$genan# carbon #ioxi#e&:%ite bloo# cells!(ostl$ neutrop%ils!also (igrate into t%ealveoli an# fill t%enor(all$ air*containing spaces&-reas of t%e lungsare not a#e/uatel$ventilate# becauseof secretions an#(ucosal e#e(at%atcause partialocclusion of t%ebronc%i or alveoli!+it% a resultant

S%ort ter()

-fter 1 %ours of NI!t%e patient +ill#e(onstratebe%aviors to i(proveor (aintain air+a$patenc$&

2ong ter()-fter 1 #a$s of NI!t%e patient +ill#e(onstrateabsence orre#uction ofcongestion +it%breat% soun#s clear!respirationsnoiseless an#i(prove# ox$genexc%ange&

>Establis% rapport


>Monitor 4S

>-uscultate breat%soun#s

>-ssess respirator$(ove(ents an# useof accessor$(uscles

>Observe for signsan# s$(pto(s ofinfection

>to gain trust an#

cooperation

>to #eter(ine s5sx


>to note presenceof a#ventitiousbreat% soun#s

>use of accessor$(uscles to breat%ein#icates an#abnor(al increasein +ork ofbreat%ing

>to i#entif$infectious processan# pro(ote ti(el$interventions

S%ort ter()

-fter 1 %ours of NI!t%e patient s%all%ave#e(onstrate#be%aviors toi(prove or(aintain air+a$patenc$&

2ong ter()-fter 1 #a$s of NI!t%e patient s%all%ave#e(onstrate#absence orre#uction ofcongestion +it%breat% soun#sclear! respirationsnoiseless an#i(prove# ox$genexc%ange&

138


6/21

* c$anosis #ecrease in alveolarox$gen tension& -ni(balance in ox$genan# carbon #ioxi#eexc%ange (a$ be

evi#ent in t%epatient3s arterialbloo# gases& -#ecrease in ox$gensuppl$ (a$ causeconfusion an#let%arg$&

>Monitor c%estra#iograp% reports

>Evaluate pulse

oxi(eter to#eter(ineox$genation

>8se positioning b$placing on a se(i*%ig% fo+ler3s position

>Elevate %ea# ofbe# or c%angeposition ever$ ,%ours an# prn

>Maintain a#e/uate%$#ration +%enpossible +it%precautions on flui#overloa#

>.erfor(nebuli"ation an#C.' as in#icate#

>Institute suctioningas nee#e#

>8se naso*p%ar$ngeal 5 oro*

>to (onitor t%eseverit$ of t%e#isease

>to assess

respirator$insufficienc$

>to facilitate lungexpansion

> to takea#vantage ofgravit$ #ecreasingpressure on t%e

#iap%rag( an#en%ancing#rainage orventilation to#ifferent lungseg(ents

>to ai# in t%e(obili"ation ofsecretions

>to loosensecretions

> to clear air+a$+%en secretionsare blocking t%eair+a$

> to %ave patentair+a$ t%roug%

&

139


7/21


8/21

at least gra#e ; leftventricular #iastolic#$sfunction* elevate# C '%e patient (a$(anifest)* confusion* let%arg$* abnor(al -093s* c$anosis

contributing factorsinclu#e #ilation oft%e left ventricle+%ic% in%ibits itsnor(al pu(ping

abilit$! t%us re#ucingt%e bloo# suppl$ t%att%e %eart an# tissues#e(an#& -lso! incases of lo+%e(oglobin an#%e(atocrit levels!t%e tissues +oul# notreceive t%e a#e/uatea(ount of ox$gent%e$ nee#! an# if leftuntreate# +oul#

result to isc%e(ia+%ic% (a$ lea# toan infarction& Certaincar#iac (arkers (a$be use# to #iagnosean infarction suc% asC Maintain opti(alcar#iac output

> Encourage /uiet!restful at(osp%ere

> Caution patient toavoi# activities t%atincrease car#iac+orkloa#&Encourage earl$a(bulation! ifpossible

> Explain possiblefactors t%at (a$boost t%e occurrenceof ineffective tissueperfusion

> I#entif$ c%anges r5ts$ste(ic orperip%eral alterationsin circulation

>-#(inister

cause facilitatespro(pt! effectivetreat(ent&

> '%is ensuresa#e/uate perfusionof vital organs&Support (a$ bere/uire# to facilitateperip%eralcirculation 6e&g&!elevation ofaffecte# li(b!antie(bolis(#evices7

> to conserveenerg$ an# lo+erstissue O, #e(an#s

> to (axi(i"etissue perfusion

> 'o i(posea+areness on t%epatient an# SO

> 'o evaluate iffurt%er co(plications+ill occur

>Drugs t%at i(prove

t%e patient s%all%ave#e(onstrate#absence orre#uction of

congestion +it%breat% soun#sclear! respirationsnoiseless an#i(prove# ox$genexc%ange&&

141


9/21

(e#ications +it%caution

>Discuss in#ivi#ual

risk factors

>Instruct in bloo#pressure (onitoringat %o(e

perfusion also carr$t%e risk of a#verseresponse

>Infor(ation

necessar$ for clientto (ake infor(e#c%oices aboutre(e#ial risk factorsan# co((it(ent tolifest$le c%anges! asappropriate! topreventco(plications or(anage s$(pto(s+%en present

>Bacilitates(anage(ent of%$pertension +%ic%is a (ajor risk factorin t%e #a(age ofbloo# vessels ororgan #$sfunction&

Problem#: *ecrease Cariac +utput





S> t%e patient (a$verbali"e)* s%ortness of breat%5#$spnea* fatigue* anxiet$

O> '%e patient(anifeste#)* #ilate# leftventricle +it%

Decrease# car#iacoutput r5t altere#stroke volu(e

'%e %$poxic tissue in($ocar#ial infarction+it%in t%e bor#er"one (a$ beco(e asite for generatingarr%$t%(ias&Infracte# tissue #oesnot contribute totension generation#uring s$stole! an#t%erefore can alter

S%ort ter()-fter 1 %ours of NI!t%e patient +illparticipate inactivities t%at#ecrease t%e+orkloa# of t%e %eartsuc% as stress(anage(entor t%erapeutic(e#ication regi(en

>Establis% rapport


>Monitor 4S

>Monitor EC9 for

> to gain trust an#cooperation

> to #eter(inesigns an#s$(pto(s

> to obtain baseline#ata

> #ecrease in

S%ort ter()-fter 1 %ours of NI!t%e patient s%all%ave participate#in activities t%at#ecrease t%e+orkloa# of t%e%eart suc% asstress(anage(entor t%erapeutic

142


10/21

seg(ental +all(otion abnor(alities* severel$ #epresse#left ventriculars$stolic function +it%

at least gra#e ; leftventricular #iastolic#$sfunction* +it% ox$gen%ooke# via nasalcannula regulate# at, lp(* +it%con#o(cat%eterattac%e# to urinebag* continuous car#iac

(onitoring

'%e patient (a$(anifest)* #$sr%$t%(ias* EC9 c%anges* c$anosis* pallor* prolonge# capillar$refill* #ecrease#perip%eral pulses* variations in bloo#pressure rea#ings

ventricular s$stolican# #iastolic functionan# #isrupt electricalactivit$ +it%in t%e%eart& :it%out

i(prove(ent! t%e%eart (uscles (a$un#ergo re(o#elingsuc% as %$pertrop%$!losing its nor(alpu(ping abilit$! t%us(a$ causeina#e/uate bloo# to(eet t%e nee#s oft%e bo#$3s tissues&Car#iac output an#tissue perfusion are

interrelate#! t%us a#ecrease in car#iacoutput (a$ bringabout c$anosis!pallor an# prolonge#capillar$ refill& '%ere(a$ also be fatiguean# s%ortness ofbreat% as t%ere isnot enoug% ox$gensupplie# to t%etissues&

progra(

2ong ter()-fter 1 #a$s of NI!t%e patient +ill#ispla$%e(o#$na(icstabilit$ -E0nor(ali"ation ofEC9 tracings an#bloo# pressurerea#ings

#$srr%$t%(ias!con#uction #efectsan# for %eart rate

>Monitor car#iacr%$t%(scontinuousl$

>Encourage patientto #ecrease intake ofcaffeine! cola an#c%ocolates

>Observe skin color!

te(perature!capillar$ refill ti(ean# #iap%oresis

>Monitor intake an#output an# calculate,1 %our flui# balance

>-#(inistersupple(entalox$gen as in#icate#

>-#(inister(e#icines asprescribe# b$ t%ep%$sician

>.ro(ote a#e/uate

car#iac output (a$result in c%anges incar#iac perfusioncausing#$sr%$t%(ias

> to note foreffectiveness of(e#icines

> caffeine is acar#iac sti(ulantan# (a$ a#versel$affect car#iacfunction

> perip%eral

vasoconstriction(a$ result in pale!cool! cla(($ skin!+it% prolonge#capillar$ refill ti(e#ue to car#iac#$sfunction an##ecrease# car#iacoutput

> to (aintaina#e/uate nutritionan# flui# balance

> to provi#e fora#e/uateox$genation

> to pro(ote+ellness

> to #ecrease

(e#icationregi(en progra(

2ong ter()

-fter 1 #a$s of NI!t%e patient s%all%ave #ispla$e#%e(o#$na(icstabilit$ -E0nor(ali"ation ofEC9 tracings an#bloo# pressurerea#ings

143


11/21

rest b$ #ecreasingsti(uli provi#ing/uiet environ(ent

>Encourage

c%anging positionsslo+l$! #angling legsbefore stan#ing

>Instruct client fa(il$ on flui# an##iet re/uire(entsan# restrictions ofso#iu(

> instruct client an#fa(il$ on(e#ications! si#eeffects!contrain#icationsan# signs to report

ox$genconsu(ption

> to prevent

occurrence ofort%ostatic%$potension

> restrictions canassist +it%#ecrease in flui#retention an#%$pertension!t%ereb$ i(provingcar#iac output

> pro(oteskno+le#ge an#co(pliance +it%#rug regi(en

Problem#,: -is. for Aspiration





S> O

O> t%e patient(anifeste#)* +it% pro#uctivecoug%* +it% presence ofcrackles on lo+erlobe of t%e rig%t lung* +it% ox$gen%ooke# via nasalcannula regulate# at

Risk for -spiration r5tpresence of retaine#secretions

.neu(onai is aserious infection t%ataffects t%e airsacs+it% acco(pan$ingsecretions t%at (a$be expectorate#&Su##en coug%ing(a$ (obili"e t%esecretions an# (a$reac% t%e air+a$+%ic% (a$ cause#istress to t%e

S%ort ter()-fter 1 %ours of NI!t%e patient +ill befree fro( aspiration-E0 %aving a patentair+a$

2ong ter()

>Establis% rapport


>Monitor 4S

> Monitor level ofconsciousness

>to gain trust an#cooperation

>to #eter(ine signsan# s$(pto(s

>to obtain baseline#ata&

> - #ecrease# levelof consciousness isa pri(e risk factor

S%ort ter()-fter 1 %ours ofNI! t%e patients%all be free fro(aspiration -E0%aving a patentair+a$

144


12/21

, lp(* +it% con#o(cat%eter attac%e# tourine bag* continuous car#iac

(onitoring

>t%e patient (a$(anifest)* respirator$ #istress

patient3s breat%ing+%ic% is fatal&8suall$ +%enso(eone aspiratest%e$ coug% in an

atte(pt to clear t%efoo# or flui# out oft%eir lungs&

-fter , #a$s of NI!t%e patient +illexperience noaspiration -E0noiseless

respirations an#clear breat% soun#s

> Notif$ t%e p%$sicianor ot%er %ealt% careprovi#er i((e#iatel$of note# #ecrease incoug% an#5or gagreflexes or #ifficult$in s+allo+ing

>-ssist +it% postural#rainage

>.rovi#e a restperio# prior tofee#ing ti(e

>Mini(i"e use ofse#atives5%$pnotics+%enever possible&

>.rovi#e infor(ationon t%e effect ofaspiration on t%elungs

for aspiration

> '%is is necessar$to (aintain a patentair+a$

> Earl$ interventionprotects t%e patient3sair+a$ an# preventsaspiration

>to (obili"et%ickene# secretions+%ic% (a$ causei(pair(ent ins+allo+ing

>t%e reste# client(a$ %ave less#ifficult$ ins+allo+ing

>t%ese agents cani(pair coug%ing ors+allo+ing

>severe coug%ingan# c$anosisassociate# +it%eating or #rinking orc%anges in vocal/ualit$ afters+allo+ing in#icatesonset of respirator$s$(pto(sassociate# +it%aspiration an#re/uires i((e#iate

2ong ter()-fter , #a$s of NI!t%e patient s%all%aveexperience# no

aspiration -E0noiselessrespirations an#clear breat%soun#s

145


13/21

>Refer

interventions&

>to pro(otecontinuit$ of care

Problem#/: Aniety

CuesNursing

DiagnosisScientif ic Explanation Objectives



S OO pt& (anifeste#

*+it% goo# skin turgor*+it% pale palpebralconjunctiva*+it% capillar$ refill ,secon#s* Col# cla(($ skin*+it% ox$gen %ooke#via nasal cannularegulate# at , lp(*+it% con#o(cat%eter attac%e# tourine bag*continuous car#iac(onitoring

.t& (a$ (anifest)

*Sleep #isturbance*Restlessness*'ac%$car#ia*'ac%$pnea

-nxiet$ r5tperceive# 5actualt%reat of #eat%!pain! possiblelifest$le c%angesb$ restlessness

Coping +it% t%e painan# e(otional trau(a is#ifficult& .atient (a$ fear#eat% an# or be anxiousabout i((e#iateenviron(ent& Ongoinganxiet$ 6relate# toconcerns about i(pactof %eart attack on futurelifest$le! (atters leftunatten#e#5unresolve#an# effects of illness onfa(il$7 (a$ be presentin var$ing #egrees forso(e ti(e an# (a$be(anifeste# b$s$(pto(s of #epressionsuc% as sleep#isturbance an#restlessness&

S%ort ter()

-fter ;*1 %ours ofnursingintervention pt +illi#entif$ %ealt%$

+a$s to #eal +it%an# expressanxiet$&

2ong ter()

-fter ; #a$s ofnursingintervention pt& +illappear relaxe#an# report anxiet$is re#uce# to a(anageable level&

>Establis% rapport


>Monitor vital signs

>Observe forverbal5non*verbalsigns of anxiet$! an#sta$ +it% t%e pt&Intervene if ptispla$s #estructivebe%avior&

>Maintain confi#ent(anner 6+it%out falsereassurance7

>Orient pt5SO toroutine proce#uresan# expecte# activities

>.rovi#e privac$ forpt& an# SO&

>'o gain trust an#cooperation

>'o (onitorp%$siologiccon#ition

>'o %ave baseline#ata

>to %elp pt& regaincontrol of o+nbe%avior

>%onestexplanation canalleviate anxiet$

>pre#ictabilit$ an#participation can#ecrease anxiet$

>-llo+s nee#e#ti(e for personalexpression of

S%ort ter()

-fter ;*1 %oursof nursingintervention pts%all %ave

i#entifie# %ealt%$+a$s to #eal +it%an# expressanxiet$&

2ong ter()

-fter ; #a$s ofnursingintervention pt&s%all %aveappeare#relaxe# an#reporte# anxiet$is re#uce# to a(anageablelevel&

146


14/21

>.rovi#e restperio#s5uninterrupte#sleep! /uietsurroun#ings&

>Raise si#e rails

>E(p%asi"ei(portance ofa#e/uate nutritionalintake&

>Regulate an# (onitorI4 flui#&

>-#(inister(e#ications asor#ere#

feelings! (a$en%ance (utualsupport an#pro(ote (orea#aptive be%aviors&

>Conserves energ$an# en%ancescoping abilities&

>to provi#e safet$

> 'o (aintaingeneral goo#%ealt%&

>'o pro(ote flui#(anage(ent&

>Bor opti(u(+ellness

Problem#0: atigue





S > agad akonapapagod, tulad

pag maglalakad atmaliligo ako

O> '%e patient(anifests)

col# cla(($ skin

#r$ skin

+eakness even

+it% si(ple activities

Batigue r5t #ecreaseox$genation an#perfusion ,pul(onar$congestion

Batigue is anover+%el(ingsustaine# sense ofex%austion an##ecrease# capacit$for p%$sical an#(ental +ork at usuallevel& Insulin issecrete# b$ betacells! +%ic% are oneof four t$pes of cells

S%ort ter() -fter ; %ours ofnursing interventionspatient +ill be able toperfor( -D2s an#participate in #esire#activities at level ofabilit$&

2ong ter()

>Establis% rapport


> Monitor vital signs

>to gain t%e trustan# cooperation oft%e patient&

>to %ave a general%ealt% status of t%epatient&


S%ort ter() -fter ; %oursnursinginterventionspatient s%all %aveperfor(e# -D2san# participate in#esire# activitiesat level of abilit$&

147


15/21

capillar$ refill F ;

sec&

crackles on t%e

rig%t lung fiel#

v5s taken an#

recor#e# as follo+s)';GC! RR,?cp(! .RGH bp(!0.?;@5@ ((Jg&

'%e patient (a$(anifests)

restlessness tac%$pnea

in t%e islets of2anger%ans in t%epancreas! insulin is astorage %or(one!+%en a person eats

a (eal! insulinsecretion increasesan# (ove glucose tot%e bloo#! into(uscle! liver! an# fatcells& Due to DMt$pe , t%ere isinsulin resistance ori(paire# insulinsecretion +%ic%results in t%ein%ibit ion of t%etransport an#(etabolis( ofglucose into energ$lea#ing to eas$fatigabilit$ -E0 b$pt& +eakness even#oing activities of#ail$ living&

-fter ? #a$ ofnursing interventionspatient +ill reporti(prove sense ofenerg$&

> Instruct patient toincrease flui# intakeup to * ?@ glassesof +ater

> Instruct to sitinstea# of stan#ing#uring activities ors%o+er

>Instruct patient toincrease intake ofvita(in or ironsupple(entation likejuice

>Stretc% linens

>-ssist +it% self*care nee#s like keepbe# in lo+ position

>Stress proper %an#+as%ing

>-#(inister #rugsas or#ere#&

> a source of energ$an#to prevent#e%$#ration

> to conserveenerg$

> to pro(ote overall%ealt% (easures&

>to provi#e co(fort

>'o conserveenerg$

>to prevent infection&

> for opti(u(+ellness

2ong ter() -fter ? #a$ ofnursinginterventionspatient s%all %ave

reporte# i(provesense of energ$&

Problem#: -is. for Infection


ExplanationObjectives Nursing Interventions Rationale Evaluation

S> O

O> '%e patient(anifeste#)* pro#uctive coug%* +it% ox$gen%ooke# via nasalcannula regulate#

Risk for Infection r5tina#e/uate pri(ar$#efenses6#ecrease# ciliar$action7

8pper air+a$c%aracteristicsnor(all$ preventpotentiall$ infectiousparticles fro(reac%ing t%e sterilelo+er respirator$tract& .neu(onia

S%ort ter()-fter , %ours ofnursing interventionpatient +ill i#entif$interventions toprevent5re#ucerisk5sprea#of5secon#ar$

>Establis% rapport


>Monitor 4S


>to #eter(ine s5sx


S%ort ter()-fter , %ours ofNI! t%e patients%all %avei#entifie#interventions toprevent5re#ucerisk5sprea#

148


16/21

at , lp(* +it% con#o(cat%eter attac%e# tourine bag* continuous

car#iac (onitoring

> '%e patient (a$(anifest)* fever* c%ills* DO0* increase in RR!.R* increase in :0Clevels an#neutrop%ils

involves t%einfla((ation of t%elung parenc%$(a+%ic% eventuall$lea#s to a

#ecrease# ciliar$action an# (a$furt%er lea# to stasisof respirator$secretions t%e clientis at r isk for t%esprea# of infectionsince t%e continuouspro#uction of (ucussecretions is aperfect bree#ingplace for(icroorganis(s&-n# if t%e bo#$ #oesnot cope +ell t%einfection (a$ sprea#to t%e rest of t%ebo#$&

infection&

2ong ter()

-fter 1 #a$s of NI!t%e patient +i llac%ieve ti(el$resolution of currentinfection +it%outco(plications&

>Obtain appropriatetissue5flui# speci(ens

>Stress proper %an#+as%ing tec%ni/ues b$all care givers bet+eent%erapies an# client

>Encourage coug%ing! position c%ange

>Monitor client3svisitors or caregiversfor presence ofrespirator$ illnesses&Offer (asks5tissues toclient5visitors +%o arecoug%ing or snee"ing

>Encourage #eepbreat%ing! coug%ingan# fre/uent positionc%anges

> Encourage a#e/uaterest balance# +it%(o#erate activit$&.ro(ote a#e/uatenutritional intake

>-#(inister or (onitor(e#ication regi(enan# note client3sresponse

>for observation forculture an#sensitivit$ testing

> it is a first line#efense againstnosoco(ialinfection or crossconta(ination

>for (obili"ation ofrespirator$secretions

>to li(it exposures!t%us re#uce crossconta(ination

>for (obili"ation ofsecretions an#prevention ofaspiration orrespirator$infection

> Bacilitates %ealingprocess an#en%ances naturalresistance&

>to #eter(ineeffectiveness oft%erap$ an#presence of si#eeffects

of5secon#ar$infection&&

2ong ter()-fter 1 #a$s of NI!t%e patient s%all%ave ac%ieve#ti(el$ resolutionof current infection+it%outco(plications

149


17/21

>-#(inisterprop%$lactic antibioticas in#icate#

> Investigate su##enc%anges5#eteriorationin con#ition! suc% asincreasing c%est pain!extra %eart soun#s!altere# sensoriu(!recurring fever!c%anges in sputu(c%aracteristics

>Revie+ in#ivi#ualnutri tional nee#s!appropriate exerciseprogra( an# nee# forrest

>E(p%asi"e nee#s fortaking antiviral orantibiotics as #irecte#

>.rovi#e infor(ation orinvolve in appropriateco((unit$ an# nationale#ucation progra(s

>to correct norre#uce existing riskfactors

> Dela$e# recover$or increase inseverit$ ofs$(pto(ssuggestsresistance toantibiotics orsecon#ar$ infection

>to pro(ote+ellness

>.re(ature#iscontinuation oftreat(ent +%enclient feels +ell(a$ result in returnof infection an#(a$ potentiate#rug*resistantstrains

>to increasea+areness of an#prevention ofao((unicable#iseases

150


18/21

Problem#1: Activity Intolerance


Explanation ObjectivesNursing

Interventions Rationale EvaluationS> '%e pt& (a$verbali"e)* exertional #$spneaor #isco(fort* reports of fatigue or+eakness

O> t%e patient(anifeste#)* nee# for assistanceupon (ove(ent* li(ite# range of(otion* +it% ox$gen%ooke# via nasalcannula regulate# at, lp(* +it%con#o(cat%eterattac%e# to urinebag* continuous car#iac(onitoring

'%e patient (a$(anifest)* tac%$pnea an#increase# bloo#pressure uponperfor(ance ofactivities* pallor* c$anosis* isc%e(ic EC9

-ctivit$ Intolerancer5t car#iac#$sfunction!i(balance in ox$gensuppl$ an#consu(ption asevi#ence# b$s%ortness of breat%upon exertion

'%e un#erl$ing(ec%anis( of a%eart attack is t%e#estruction of %eart(uscle cells #ue to alack of ox$gen& Ift%ese cells are notsupplie# +it%sufficient ox$gen b$t%e coronar$ arteriesto (eet t%eir(etabolic #e(an#s!t%e$ #ie b$ aprocess calle#infarction& '%e#ecrease in bloo#suppl$ (a$ bringabout necrosis of t%e%eart (uscle +%ic%+oul# (ake it+eaker as a pu(p&-s a result! t%epu(ping (ec%anis(of t%e %eart +ill beineffective t%usgiving t%e in#ivi#ualan insufficient suppl$of bloo#! bringingabout an inefficientsuppl$ of ox$gen tot%e t issues t%uslea#ing to eas$fatigabilit$ uponsi(ple exertions& If

S%ort ter()-fter 1 %ours of NI!t%e patient +ill usei#entifie# tec%ni/uesto increase activit$tolerance&

2ong ter()-fter 1 #a$s of NI!t%e patient +ill beable to increase an#ac%ieve #esire#activit$ level!progressivel$! +it%no intolerances$(pto(s note#!suc% as respirator$co(pro(ise&

>Establis% rapport


>Monitor 4S

>I#entif$ causativefactors lea#ing tointolerance of activit$

>Encourage patientto assist +it%planning activities!+it% rest perio#s asnecessar$

>Instruct patient inenerg$ conservationtec%ni/ues

>-ssist +it% activeor passive ROM


>to #eter(ine signsan# s$(pto(s

>c%anges in 4Sassist +it%(onitoringp%$siologicresponses toincrease in activit$&

>al leviation offactors t%at arekno+n to createintolerance canassist +it%#evelop(ent of anactivit$ levelprogra(

> to %elp give t%epatient a feeling ofself*+ort% an# +ell*being

> to #ecreaseenerg$ expen#iturean# fatigue

> to (aintain joint(obilit$ an# (uscle

S%ort ter()-fter 1 %ours of NI!t%e patient s%all%ave use#i#entifie#tec%ni/ues toincrease activit$tolerance&

2ong ter()-fter 1 #a$s of NI!t%e patient s%all%ave increase#an# ac%ieve##esire# activit$level!progressivel$! +it%no intolerances$(pto(s note#!suc% asrespirator$co(pro(ise

151


19/21


20/21

in (onitoringresponse to activit$an# recogni"ingsigns an# s$(pto(s

nee# in alteration ofactivities

Problem#11: 4elf Care *eficit r't wea.ness





S > KO> '%e patient(anifests)

col# cla(($

skin

goo# skin turgor

capillar$ refill F ;sec&

irritabilit$

+eakness +%en

taking a bat%

eas$ fatigabilit$

even onl$ #oing-D2s

'%e patient (a$(anifests)

restlessness

Self care #eficitrelate# to +eaknessor tire#ness&

'%e nurse (a$encounter t%epatient +it% self *care #eficit in t%e%ospital& '%e #eficit(a$ be a result oftransient li(itations!suc% as t%ose one

(ig%t experience+%ile recoveringfro( surger$ or t%eresult of t%eprogressive#eterioration t%atero#es t%ein#ivi#ual3s abilit$ or+illingness toperfor( t%e activitiesre/uire# to care for%i(self& Careful

exa(ination of t%epatient3s #eficit isre/uire# in or#er tobe certain t%at t%epatient is not failingself*care because oflack of (aterials +it%arranging t%eenviron(ent to suitt%e patient3s p%$sicalli(itations&

S%ort ter() -fter ; %ours ofnursing interventionspatient +ill be able toverbali"eun#erstan#ing ont%e i(portance ofself*care&

2ong ter() -fter ? #a$ ofnursing interventionspatient +ill safel$perfor( self*careactivities&

>Establis% rapport


> Monitor vital signs

>-ssist +it%necessar$a#aptations toacco(plis% -D2s

> -rrange forassistive #evices asnecessar$ 6seat5grabbars7

>Instruct patient toincrease flui# intakeup to * ?@ glassesof +ater

>Encourage foo#c%oices reflectingin#ivi#ual likes an#abilities t%at (eetnutritional nee#s

>to gain t%e trustan# cooperation oft%e patient&

>to %ave a general%ealt% status of t%epatient&


> to encourage an#buil# on successes

> to prevent injur$

> to prevent#e%$#ration an# asource of energ$

> to increase energ$

S%ort ter() -fter ; %oursnursinginterventionspatient s%all %aveverbali"e# t%ei(portance of self*care&

2ong ter() -fter ? #a$ ofnursinginterventionspatient s%all %aveperfor(e# safel$self*care activities&

153


21/21

>Stretc% linens

>Stress proper %an#+as%ing

>Instructe# patientto perfor( goo#%$giene

>-#(inister #rugsas or#ere#&

>to provi#e co(fort

>to prevent infection&

>'o relieve patientan# provi#e co(fort

> for opti(u(+ellness

154

30764524-“acute-coronary-syndrome-non-st-elevation-myocardial-infarction-hypertensive-cardiovascular-disease-diabetes-mellitus-type-2-and-community-acquired...

Documents