Name: Mr.

Heartbreaker Age: 52 years old Ward: Andrew Hall 1

Chief Complaint: abdominal pain Diagnosis: Aortic Stenosis, Cardiomegaly, CHF , Ac!te "idney n#!ry secondary to sc$emic %ep$ropat$y wit$ Complicated &'
CUES NURSING
DIAGNOSIS
SCIENTIFIC
RATIONALE
E!ECTED
OUTCO"E
NURSING
INTER#ENTIONS
RATIONALE E#ALUATION
S&()*C'+*:
,%ad!d!-as daw it
akon im-im yakan nira
ngan it akon k!lo
nagb!b!r!sag gi$ap.
as /erbali0ed by t$e
patient.
,1anay tigda la
nalipong nak !lo labi
na k!n nab!$at ako.
as /erbali0ed by t$e
patient.
,%agk!k!ri gi$ap ako
paggin$awa. as
/erbali0ed by t$e
patient
2()*C'+*S:
+3S taken as 4ollows:
'5 67.1 8C
995 61cpm
H95 7:bpm
(;5 1<:3=: mm
Hg
1ecrease
$emoglobin co!nt
>115g3d?@%51<2-
1=5g3d?
;allor
;ale nail beds
;ale lips
S$ortness in
breat$
ne44ecti/e tiss!e
per4!sion related to
/asoconstriction
secondary to
redistrib!tion o4
cardiac o!tp!t to /ital
organs
+asoconstriction
mediated by t$e
sympat$etic ner/o!s
system is largely
responsible 4or t$e
redistrib!tion o4
cardiac o!tp!t w$ic$
ser/es as an important
compensatory
mec$anism w$en 4low
is red!ced. '$is
redistrib!tion is most
marked w$en a patient
wit$ $eart 4ail!re
eAercises or w$en an
additional b!rdened is
imposed, s!c$ as
4e/er or anemia, b!t
as $eart 4ail!re
ad/ances,
redistrib!tion occ!rs
e/en in t$e basal
state. (lood 4low is
redistrib!ted so t$at
t$e deli/ery o4 oAygen
to /ital organs, s!c$
as t$e brain and
myocardi!m, is
maintained at normal
or near normal le/els,
w$ile 4low to less
critical areas, s!c$ as
c!taneo!s and
m!sc!lar beds and
splanc$nic /iscera
w$ic$ res!lts to
ine44ecti/e per4!sion to
t$ese areas.
SH29' '*9M:
A4ter 7 $o!rs o4
n!rsing inter/ention,
t$e patient will be able
to maintain
$emodynamic stability
as e/idenced by:
1ecrease blood
press!re and
warm skin
Minimi0e report o4
c$est pain
%ormal capillary
re4ill
Skin, palpebral
con#!ncti/a, nasal
m!cosa, lips, oral
m!cosa and g!ms
o4 nat!ral pale,
pink color
Absence or
alle/iation o4
lig$t$eadedness
?2%B '*9M:
A4ter 1 week o4 n!rsing
inter/ention, t$e
patient will be able to
demonstrate increase
tiss!e per4!sion as
e/idenced by:
%o signs o4 pallor
Able to per4orm
A1?Cs wit$o!t
di44ic!lty and
dyspnea.
1. Assess general
condition o4 t$e
patient.
2. Assess /ital signs.
6. Assess skin 4or
coolness, pallor.
<. ;ro/ide a warm
en/ironment.
5. ;er4orm capillary
re4ill test.
7. Monitor !rine o!tp!t.
=. *nco!rage D!iet,
rest4!l atmosp$ere.
E. *nco!rage acti/e
range o4 motion b!t
pro/ide rest periods.
F. *le/ate bed at nig$t.
C2??A(29A'+*
1:. Administer
medications as
prescribed:
soket >isosorbide
1. 'o assess t$e
c!rrent stat!s o4
clientCs condition.
2. 'o obtain baseline
data.
6. May indicate
$ypoAemia.
<. A warm en/ironment
promotes
/asodilation, w$ic$
decreases preload
and tiss!e
per4!sion.
5. 'o c$eck t$e
adeD!acy o4 blood
4low or circ!lation.
7. 1ecreased
per4!sion to t$e
kidneys may res!lt
in olig!ria.
=. Conser/es energy
and lowers tiss!e
22 demand.
E. 9ange o4 motion
$elps decrease
/eno!s pooling and
promotes tiss!e
per4!sion.
F. 'o increase
gra/itational blood
4low.
G;romotes perip$eral
/asodilation and
Boals partially met
A4ter n!rsing
inter/entions, t$e client
$ad:
1ecreased blood
press!re wit$ warm
skin
Minimi0ed report o4
c$est pain
Capillary re4ill normal
%ormal skin,palpebral
con#!ncti/a, nasal
m!cosa, lips, oral
m!cosa and g!m
color
Absence o4
lig$t$eadedness
Absence o4 pallor
Has able to per4orm
some o4 $is A1?Cs like
sel4 care wit$ less
di44ic!lty
;atientCs $ematologic
res!lt slig$tly
increased.
C$est pain
1elayed capillary
re4ill >< seconds@%-
(ody malaise and
acti/ity intolerance
Fatig!e
Abnormal A(B
res!lt >pH5=.56:
%5=.65:-=.<5:I
pC2251F.6mmHg
%565-<5I
p225116mmHg
%5E:-1::@
Additional
1iagnosis: Ac!te
kidney in#!ry
secondary to
isc$emic
nep$ropat$y
secondary to CHF,
complicated &'
Final diagnosis:
se/ere aortic
stenosis,
cardiomegaly, CHF
ascites
Foc!s on
;at$op$ysiology page
<=7 by (arbara ?.
(!llock and 9eet ?.
Hen0e
;atientCs
$ematologic
laboratory res!lts
will be normal or at
least increase in
/al!e
dinitrate@ 2:mg 1 tab 21
Sim/astatin
>anti$yperlipidemic@
2:mg 1 tab 21
(isoprolol
>anti$ypertensi/e@ 5mg
J tab (1
11. Monitor A(B.
12. 2Aygen
administration as
prescribed.
red!ces preload and
a4terload, decreasing
myocardial oAygen
cons!mption and
increasing cardiac
o!tp!t. Also dilates
coronary arteries,
increasing blood 4low
and impro/ing collateral
circ!lation
Gn$ibits t$e en0yme
t$at cataly0es t$e 4irst
step in t$e c$olesterol
synt$esis pat$way,
res!lting in decrease in
ser!m c$olesterol, and
ser!m ?1?Cs.
G1ecreases t$e
eAcitability o4 t$e $eart,
t$!s decreasing t$e
cardiac o!tp!t and
oAygen cons!mption,
decreasing t$e release
o4 rennin 4rom t$e
kidney, and lowering t$e
(;.
11. denti4ies
$ypoAemia,
e44ecti/eness or
need 4or
t$erapy.
12. 'o promote
adeD!ate tiss!e
per4!sion.