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    NCP

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    Krizelle Abadesco Libo-on
    The 68-year-old patient presented with increased blood pressure, dyspnea with exertion, fatigue, and weakness. The diagnoses were activity intolerance due to cardiac dysfunction as evidenced by shortness of breath, and ineffective cardiac tissue perfusion due to a previous myocardial infarction. Nursing interventions included monitoring vital signs, instructing the patient in energy conservation and breathing techniques, and ensuring adequate rest. The goals of reducing dyspnea with activity and increasing the activity level were met within the target timeframes.

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    NCP

    Uploaded by

    Krizelle Abadesco Libo-on
    1K views3 pages
    The 68-year-old patient presented with increased blood pressure, dyspnea with exertion, fatigue, and weakness. The diagnoses were activity intolerance due to cardiac dysfunction as evidenced by shortness of breath, and ineffective cardiac tissue perfusion due to a previous myocardial infarction. Nursing interventions included monitoring vital signs, instructing the patient in energy conservation and breathing techniques, and ensuring adequate rest. The goals of reducing dyspnea with activity and increasing the activity level were met within the target timeframes.

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    The 68-year-old patient presented with increased blood pressure, dyspnea with exertion, fatigue, and weakness. The diagnoses were activity intolerance due to cardiac dysfunction as evidenced by shortness of breath, and ineffective cardiac tissue perfusion due to a previous myocardial infarction. Nursing interventions included monitoring vital signs, instructing the patient in energy conservation and breathing techniques, and ensuring adequate rest. The goals of reducing dyspnea with activity and increasing the activity level were met within the target timeframes.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    1K views3 pages

    NCP

    Uploaded by

    Krizelle Abadesco Libo-on
    The 68-year-old patient presented with increased blood pressure, dyspnea with exertion, fatigue, and weakness. The diagnoses were activity intolerance due to cardiac dysfunction as evidenced by shortness of breath, and ineffective cardiac tissue perfusion due to a previous myocardial infarction. Nursing interventions included monitoring vital signs, instructing the patient in energy conservation and breathing techniques, and ensuring adequate rest. The goals of reducing dyspnea with activity and increasing the activity level were met within the target timeframes.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
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    NCP

    Name of patient: W.D Age: 68 y.o Cues Subjective: The client reports o dina hapo ako kun dina kapoy . Objective: y Increased blood pressure Bp= 140/80 y Dyspnea with exertion y Fatigue and weaknes Weakness: Age (67y.o) Strenghts: Able to comply with medications Diagnosis Activity Intolerance r/t cardiac dysfunction, changes in oxygen supply and consumption as evidenced by shortness of breath. Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities Source: NANDA Rationale Weakness and fatigue Goal STG: Within 3 days of nursing interventions, the client will be able to tolerate activity without excessive dyspnea and will be able to utilize breathing techniques and energy conservation techniques effectively. LTG: Within 5 days of nursing interventions, the client will be able to increase and achieve desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise. Intervention INDEPENDENT: 1. monitor heart rate, rhythm, respirations and blood pressure for abnormalities. Notify physician of significant changes in VS. 2. Identify causative factors leading to intolerance of activity. 3. encourage patient to assist with planning activities, with rest periods as necessary. 4. instruct patient in energy conservation techniques. 5. turn patient at least every 2 hours, and prn. 7. instruct patient in isometric and breathing exercises. CC: knap and chest pain

    Rationale 1.changes in VS assist with monitoring physiologic responses to increase in activity. 2. Alleviation of factors that are known to create intolerance can assist with development of an activity level program. 3. to help give the patient a feeling of self-worth and well-being. 4. to decrease energy expenditure and fatigue. 5. to maintain joint mobility and muscle tone. 7. to improve breathing and to increase activity level.

    evaluation STG: Within 3 days of nursing interventions, the client tolerated activity without excessive dyspnea and had been able to utilize breathing techniques and energy conservation techniques effectively. Goal was met. LTG: Within 5 days of nursing interventions, the client increased and achieved desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise. Goal was met

    Decreased oxygen

    Increased CO2 levels

    Decreased Bld pH

    Deep and labored breathing

    NCP Name of patient: W.D Age: 68 y.o Cues Subjective: Diagnosis Ineffective cardiac tissue perfusion r/t interruption of blood flow 2/t a known case of myocardial infarction Definition: Decrease resulting in the failure to nourish the tissues at the capillary level Source: NANDA Rationale Myocardial Infarction Goal After 8 hrs of nursing intervention, the pt will be able to: -reduced the BP from 140/90 To 120/80 -verbalize comfort Intervention INDEPENDENT: 1. investigate sudden changes or continued alteration in mentation 2. inspect for pallor, cyanosis, mottling, cool/clammy skin. Note strength of peripheral pulse. CC: knap and chest pain

    Rationale 1 Cerebral perfusion is directly related to cardiac output and is also influenced by electrolyte/ acid-base variations, hypoxia, and systemic emboli

    evaluation After 8 hrs on nursing intervention


    1. bp was reduced

    Objective: =BP=140/90 =lethargy =pallor =restless =cold clammy skin Weakness: Age (67y.o) Strenghts: Able to comply with medications

    Myocardial tissue is destroyed

    Critical narrowing of coronary artery

    from 140/90 to 110/70. Goal met


    2. patient was able

    reduced coronary artery blood flow deprived of an adequate supply of blood result to vasospasm of coronary artery 3. Monitor respirations, note work of breathing

    2. Systemic vasoconstriction resulting from diminished cardiac output may be evidenced by decreased skin perfusion and diminished pulse 3. Cardiac pump failure and or ischemic pain may precipitate respiratory distress: however, sudden/continued dyspnea may indicate thromboembolic pulmonary complications 4. Decreased intake/persistent nausea may result in reduced circulatingvolume, w/c negatively affects perfusion and organ function. Specific gravity measurements reflect hydration status and renal function

    to verbalize comfort. Goal met

    decreased oxygen supply ineffective cardiac tissue perfusion

    4. monitor intake, note changes in urine output. Record urine specific gravity as indicated

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