NURSING TOOL BOX SERIES

  Nursing Diagnosis Ineffective  Airway   Clearance Ineffective Breathing Pattern Impaired Gas Exchange Decreased  Cardiac Output Risk for Injury Excess Fluid Volume Impaired Physical Mobility Impaired Skin Integrity Impaired Verbal Communication Ineffective Coping Sleep Pattern Disturbance

Congestive Heart Failure (CHF)   Decreased Cardiac Output Assessment The patient may manifest the following: Pale conjunctiva, nail beds, and buccal mucosa irregular rhythm of pulse bradycardia generalized weakness Diagnosis Decreased cardiac output r/t [altered heart rate and rhythm] AEB [bradycardia] Planning Short Term: After 3-4 hours of nursing interventions, the patient will participate in activities that reduce the workload of the heart. Long Term: After 2-3 days of nursing interventions, the patient will be able to display hemodynamic stability. Nursing Interventions Assess for abnormal heart and lung sounds. Rationale: Allows detection of left-sided heart failure that may occur with chronic renal failure patients due to fluid volume excess as the diseased kidneys are unable to excrete water. Monitor blood pressure and pulse. Rationale: Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the rennin-angiotensin mec

Myocardial Infarction Nursing Care Plan   Nursing Priorities Relieve pain, anxiety. Reduce myocardial workload. Prevent/detect and assist in treatment of life-threatening dysrhythmias or complications. Promote cardiac health, self-care. Nursing diagnosis:  Pain, Acute May be related to Tissue ischemia (coronary artery occlusion) Possibly evidenced by Reports of chest pain with/without radiation Facial grimacing Restlessness, changes in level of consciousness Changes in pulse, BP Desired outcomes/evaluation criteria—patient will: Pain Level (NOC) Verbalize relief/control of chest pain within appropriate time frame for administered medications. Display reduced tension, relaxed manner, ease of movement. Pain Control (NOC) Demonstrate use of relaxation techniques. Nursing Interventions Rationale Pain Management Independent Monitor/document characteristics of pain, noting verbal reports, nonverbal cues (e.g., moaning, crying, restlessness, diaphoresis, clutching chest, rapid breathing), and