Martinez, L. G. & Bucher, L. (2010). Nursing management: Coronary artery disease and acute coronary syndrome. In Lewis, S., Heitkemper, M., Dirksen, S. R., O'Brien, P. G., Barry, M., Goldsworthy, S., & Goodridge, D. (Eds.). Medical-surgical nursing in Canada (2nd ed. pp. 846-882). Toronto, ON: Mosby Elsevier 2/2 Stenberg College RDPN Program Nursing Care Plan Nursing Desired Interventions Rationale & APA Evaluation of Diagnosis Outcomes Interventions “Reference (C) - Collaborative NDX: Goal N1-(I) (Reversal (C) R1- E1- (Problem) of Problem) Position to alleviate To improve ventilation Patient has regular, Risk for excess fluid volume Decrease dyspnea (e.g., by decreasing venous non-labored intravascular position with return to the heart and respirations R/T: volume legs dangling (p. 934). increasing thoracic capacity and facilitating Client will list : breathing(p. 943). measurable Cardiac failure outcomes; Patient is in respiratory Patient has regular, Assess ABC’S and reverse and distress and has an non-labored Pulmonary supplement patient’s symptoms increased respiratory respirations Edema oxygen by mask or rate. Oxygen will Restrict nasal catheter sodium 6 L-min increase CO and help Right and Left to 2-g per day relax the pt (p. 935). Ventricular Hypertrophy Restrict fluids to Patients lung sounds Crackles may indicate Auscultate lungs for 100 mL per day are clear to failure which can presence of normal or auscultation in all contribute to decreased Take adventitious sounds AEB: lobes cardiac output (p. 622). medications as In respiratory prescribed – distress, use of Enalapril accessory
Martinez, L. G. & Bucher, L. (2010). Nursing management: Coronary artery disease and acute coronary syndrome. In Lewis, S., Heitkemper, M., Dirksen, S. R., O'Brien, P. G., Barry, M., Goldsworthy, S., & Goodridge, D. (Eds.). Medical-surgical nursing in Canada (2nd ed. pp. 846-882). Toronto, ON: Mosby Elsevier 2/2 Stenberg College RDPN Program Nursing Care Plan Nursing Diagnosis Desired Outcomes Interventions (C) - Collaborative Rationale & APA “Reference Evaluation of Interventions NDX: (Problem) Risk for excess fluid volume R/T: Cardiac failure Pulmonary Edema Right and Left Ventricular Hypertrophy AEB: In respiratory distress, use of accessory Goal (Reversal of Problem) Decrease intravascular volume (p. 934). Client will list measurable outcomes; reverse and symptoms Restrict sodium to 2-g per day Restrict fluids to 100 mL per day Take medications as prescribed – Enalapril N1-(I) (C) Position to alleviate dyspnea (e.g., position with legs dangling Assess ABC’S and supplement patient’s oxygen by mask or nasal catheter 6 L-min Auscultate lungs for presence of normal or adventitious sounds R1- To improve ventilation by decreasing venous return to the heart and increasing thoracic capacity and facilitating breathing(p. 943). Patient is in respiratory distress and has an increased respiratory rate. Oxygen will increase CO and help relax the pt (p. 935). Crackles may indicate failure which can contribute to decreased cardiac output (p. 622). E1- Patient has regular, non-labored respirations Patient has regular, non-labored respirations Patients lung sounds are clear to auscultation in all lobes :
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