Acute Pain

Posted on |

Introduction/Pathophysiology [1,2]

Physical immobility, prolonged bed rest, alterations in nutritional status often result in impaired peripheral circulation, compromising the tissue nutrient delivery and skin integrity. Impaired skin integrity nursing diagnosis and early recognition allows for prompt intervention. Implementing the risk for impaired skin integrity care plan can help prevent further complications, especially discomfort and risk of infections.

Causes[1,2]

  • Prolonged bed rest
  • Edema
  • Decreased tissue perfusion

Symptoms[1,2]

Subjective (client may report)

  • verbal report of pain
  • altered sensation at site if tissue impairment

Objective[1]

  • Skin color changes
  • Skin redness
  • Warmth of skin
  • Skin areas demonstrating impairment

Risk factors[1]:

  • Bed rest
  • Altered circulation
  • Impaired mobility
  • Mechanical factors; shear
  • Obesity

Intervention[1]

Assessment[1]

Collect client history, including risk factors and symptoms (objective and subjective data)

Cardiac Function:

  • Abnormal heart
  • Changes in blood pressure

Respiratory function

  • Changes in breathing

Neurologic/Sensory function

  • Pain
  • Loss of sensation
  • Confusion (risk of infection)

Visual appearance/labs

  • Pallor
  • Redness
  • Breakdown of skin covering bony prominences
  • Pruritic areas
  • Perineum
  • Areas of decreased sensation

Impaired Skin Integrity Nursing diagnosis [1]

Assessment 

Inspect the skin (especially bony prominences, dependent areas, and affected extremity for pallor, redness and breakdown

Rationale: 

Presence of signs and symptoms establishes an actual diagnosis

Risk for impaired skin integrity care plan[1,2]

  • Improve blood flow
  • Minimize tissues hypoxia (massage)
  • Improve myocardial contractility/systemic perfusion
  • Proper positioning of clients, including foam blocks, pillows, bed cradles
  • Prevent complications-risk of infection
  • Provide information about disease/prognosis, therapy needs, and prevention of recurrences

Nursing actions[1,2]

Perform:

  • Skin inspection, noting skeletal prominences, areas of altered circulation, pigmentation, obesity and emaciation
  • Check for edema
  • Remove antiembolism stockings for 30-60 minutes at least twice a day
  • Notify appropriate health care providers if needed-wound care specialist, physician

Provide:

  • Frequent skin care, minimize contact with moisture/excretions
  • Provide gentle massage around the affected areas -red and blanched
    • Avoid the affected area directly as it may cause tissue injury
  • Assistance with active and passive range of motion exercises (ROM)
  • Alternating pressure/egg-crate mattress, pillows,sheepskin elbow/ heel protectors such as gel or foam cushions
    • Reduce pressure to skin, improve circulation
    • Assist client with turning every 2 hours
  • Bed cradle or footboard to relieve pressure from bed linens
  • Tools, such as foam blocks or pillows to help elevate extremities

Avoid:

  • Intramuscular route for medication-impeded drug absorption
  • Tight shoes or slippers- edema may cause shoes to. Fit poorly, increased risk of breakdown due pressure on skin on feet
  • Excessive dryness or moisture as they can damage skin and hasten breakdown

Administer:

  • Supplemental oxygen
  • Antidysrhythmic agents, Anticholinergic agents, pain medications if needed

Monitor:

  • Skin integrity
  • Skin color
  • Edema
  • Possible infection

Encourage:

  • Frequent positions changes in bed/chair-reduces pressure on tissue, improving circulation and reducing the time the area is deprived of blood flow.
  • Keeping bed linens clean and dry

Goals and Outcomes[1,2]

  • Maintain skin integrity/ no skin breakdowns
  • Absence of redness and irritation
  • Demonstrates behaviors/techniques to prevent skin breakdowns

Post intervention evaluation/monitoring [1]

Monitor[1]

  • Skin integrity
  • Skin color
  • Signs of infection-blood test

Future goals [1]

  • Maintain skin integrity
  • Prevent underlying causes
  • Client understanding and demonstration of behaviors and techniques to prevent skin breakdowns

Prevention[1,2]

  • Pressure management to prevent ulceration
  • Check for fit of shoes, slippers and change as needed
  • Control edema; interstitial edema and impaired circulation slow down drug absorption and predispose to tissue breakdown/ development of infection
  • Encourage smoking cessation
  • Educate about tips to conserve energy

Supplemental material

Client case

Client has been admitted in the NICU for 13 days after a stroke accident. Client in not ventilated anymore. Client mentions he is experiencing warmness and pain in the lower back. Client’s BMI is 37.5 and he also suffers from stage 3 kidney disease.

Questions: 

Based on the client case, what factors are predictive of impaired skin integrity?

Answer: prolonged bed rest, pain, warmness, obesity, impaired renal function

What are signs and symptoms of infection?

  1. Symptoms of sepsis
  2. Wound purulence
  3. Altered mental status
  4. Increased white blood cells
  5. All of the above

What medications should be avoided in clients with impaired skin integrity?

  1. Transdermal patches
  2. Topical agents
  3. Intramuscular route
  4. All of the above

How often and how long should antiembolism stockings be removed on a daily basis?

  1. antiembolism stockings should never be removed
  2. 30-60 minutes at least twice a day
  3. 30 minutes once a day
  4. On for 12hrs, off for 12 hours

List at least 3 tips for preventing impaired skin integrity

  1. Changing bed positions often
  2. Alternating pressure/egg-crate mattress, pillows, sheepskin elbow/ heel
  3. Ensuring proper nutrition and hydration
  4. Massaging areas of impaired circulation.
  5. Tools, such as foam blocks or pillows to help elevate extremities
  6. Using bed cradle or footboard to relieve pressure from bed linens
  7. Wearing comfortable shoes/slippers

References:

  1. Doenges, Marilynn E., et al. Nursing Care Plans: Guidelines for Individualizing Client Care. F.A. Davis, 2006.
  2. Haugen, Nancy, et al. Ulrich & Canale’s Nursing Care Planning Guides: Prioritization, Delegation, and Critical Reasoning. Elsevier, 2020.

Risk for Impaired Skin Integrity

Posted on |

risk for impaired skin integrity care plan

Introduction/Pathophysiology [1,2]

Physical immobility, prolonged bed rest, alterations in nutritional status often result in impaired peripheral circulation, compromising the tissue nutrient delivery and skin integrity. Impaired skin integrity nursing diagnosis and early recognition allows for prompt intervention. Implementing the risk for impaired skin integrity care plan can help prevent further complications, especially discomfort and risk of infections.

Causes[1,2]

  • Prolonged bed rest
  • Edema
  • Decreased tissue perfusion

Symptoms[1,2]

Subjective (client may report)

  • verbal report of pain
  • altered sensation at site if tissue impairment

Objective[1]

  • Skin color changes
  • Skin redness
  • Warmth of skin
  • Skin areas demonstrating impairment

Risk factors[1]:

  • Bed rest
  • Altered circulation
  • Impaired mobility
  • Mechanical factors; shear
  • Obesity

Intervention[1]

Assessment[1]

Collect client history, including risk factors and symptoms (objective and subjective data)

Cardiac Function:

  • Abnormal heart
  • Changes in blood pressure

Respiratory function

  • Changes in breathing

Neurologic/Sensory function

  • Pain
  • Loss of sensation
  • Confusion (risk of infection)

Visual appearance/labs

  • Pallor
  • Redness
  • Breakdown of skin covering bony prominences
  • Pruritic areas
  • Perineum
  • Areas of decreased sensation

Impaired Skin Integrity Nursing diagnosis [1]

Assessment 

Inspect the skin (especially bony prominences, dependent areas, and affected extremity for pallor, redness and breakdown

Rationale: 

Presence of signs and symptoms establishes an actual diagnosis

Risk for impaired skin integrity care plan[1,2]

  • Improve blood flow
  • Minimize tissues hypoxia (massage)
  • Improve myocardial contractility/systemic perfusion
  • Proper positioning of clients, including foam blocks, pillows, bed cradles
  • Prevent complications-risk of infection
  • Provide information about disease/prognosis, therapy needs, and prevention of recurrences

Nursing actions[1,2]

Perform:

  • Skin inspection, noting skeletal prominences, areas of altered circulation, pigmentation, obesity and emaciation
  • Check for edema
  • Remove antiembolism stockings for 30-60 minutes at least twice a day
  • Notify appropriate health care providers if needed-wound care specialist, physician

Provide:

  • Frequent skin care, minimize contact with moisture/excretions
  • Provide gentle massage around the affected areas -red and blanched
    • Avoid the affected area directly as it may cause tissue injury
  • Assistance with active and passive range of motion exercises (ROM)
  • Alternating pressure/egg-crate mattress, pillows,sheepskin elbow/ heel protectors such as gel or foam cushions
    • Reduce pressure to skin, improve circulation
    • Assist client with turning every 2 hours
  • Bed cradle or footboard to relieve pressure from bed linens
  • Tools, such as foam blocks or pillows to help elevate extremities

Avoid:

  • Intramuscular route for medication-impeded drug absorption
  • Tight shoes or slippers- edema may cause shoes to. Fit poorly, increased risk of breakdown due pressure on skin on feet
  • Excessive dryness or moisture as they can damage skin and hasten breakdown

Administer:

  • Supplemental oxygen
  • Antidysrhythmic agents, Anticholinergic agents, pain medications if needed

Monitor:

  • Skin integrity
  • Skin color
  • Edema
  • Possible infection

Encourage:

  • Frequent positions changes in bed/chair-reduces pressure on tissue, improving circulation and reducing the time the area is deprived of blood flow.
  • Keeping bed linens clean and dry

Goals and Outcomes[1,2]

  • Maintain skin integrity/ no skin breakdowns
  • Absence of redness and irritation
  • Demonstrates behaviors/techniques to prevent skin breakdowns

Post intervention evaluation/monitoring [1]

Monitor[1]

  • Skin integrity
  • Skin color
  • Signs of infection-blood test

Future goals [1]

  • Maintain skin integrity
  • Prevent underlying causes
  • Client understanding and demonstration of behaviors and techniques to prevent skin breakdowns

Prevention[1,2]

  • Pressure management to prevent ulceration
  • Check for fit of shoes, slippers and change as needed
  • Control edema; interstitial edema and impaired circulation slow down drug absorption and predispose to tissue breakdown/ development of infection
  • Encourage smoking cessation
  • Educate about tips to conserve energy

Supplemental material

Client case

Client has been admitted in the NICU for 13 days after a stroke accident. Client in not ventilated anymore. Client mentions he is experiencing warmness and pain in the lower back. Client’s BMI is 37.5 and he also suffers from stage 3 kidney disease.

Questions: 

Based on the client case, what factors are predictive of impaired skin integrity?

Answer: prolonged bed rest, pain, warmness, obesity, impaired renal function

What are signs and symptoms of infection?

  1. Symptoms of sepsis
  2. Wound purulence
  3. Altered mental status
  4. Increased white blood cells
  5. All of the above

What medications should be avoided in clients with impaired skin integrity?

  1. Transdermal patches
  2. Topical agents
  3. Intramuscular route
  4. All of the above

How often and how long should antiembolism stockings be removed on a daily basis?

  1. antiembolism stockings should never be removed
  2. 30-60 minutes at least twice a day
  3. 30 minutes once a day
  4. On for 12hrs, off for 12 hours

List at least 3 tips for preventing impaired skin integrity

  1. Changing bed positions often
  2. Alternating pressure/egg-crate mattress, pillows, sheepskin elbow/ heel
  3. Ensuring proper nutrition and hydration
  4. Massaging areas of impaired circulation.
  5. Tools, such as foam blocks or pillows to help elevate extremities
  6. Using bed cradle or footboard to relieve pressure from bed linens
  7. Wearing comfortable shoes/slippers

References:

  1. Doenges, Marilynn E., et al. Nursing Care Plans: Guidelines for Individualizing Client Care. F.A. Davis, 2006.
  2. Haugen, Nancy, et al. Ulrich & Canale’s Nursing Care Planning Guides: Prioritization, Delegation, and Critical Reasoning. Elsevier, 2020.

Risk for Impaired Gas Exchange

Posted on |

risk for impaired gas exchange care note

Introduction/Pathophysiology [1,2]

Presence of pulmonary congestion, pulmonary edema and collection of secretions can all result in impaired gas exchange. Impaired gas exchange occurs due to alveolar-capillary membrane changes, such as fluid shifts and fluid collection into interstitial space and alveoli. This leads to excess or deficit of oxygen at the alveolar capillary membrane with impaired carbon dioxide elimination. Often, metabolic compensatory changes occur, however during pulmonary edema, hypoxemia can be severe and may require immediate interventions. Early recognition of signs and symptoms of impaired gas exchange allows for prompt intervention. Using the nursing risk for impaired gas exchange care note can help alleviate clients’ symptoms of impaired gas exchange and prevent life-threatening complications.

Causes[1,2]

  • Heart failure
  • Pulmonary edema
  • Pulmonary congestion
  • COPD
  • Smoking
  • Fibrosis

Symptoms[1,2]

Subjective (client may report)

  • shortness of breath
  • difficulty breathing
  • headache upon awakening

Objective[1,2]

  • decreased CO2
  • tachycardia
  • hypercapnia
  • restlessness
  • somnolence
  • irritability
  • confusion
  • hypoxia
  • dyspnea
  • cyanosis (neonates only)
  • abnormal arterial blood gases
  • abnormal skin color-pale, dusky
  • abnormal heart rate and rhythm
  • changes in depth of breathing
  • diaphoresis
  • nasal flaring
  • low partial pressure of oxygen in arterial blood
  • low pulse oximetry

Risk factors[1,2]:

  • Heart failure
  • Infections
  • Ventilation and perfusion imbalance
  • Asthma
  • COPD
  • Emphysema
  • Neuromuscular conditions that cause fixation or weakening of the diaphragm

Intervention[1]

Assessment[1,2]

Collect client history, including risk factors and symptoms (objective and subjective data)

Cardiac Function:

  • Blood pressure
  • Heart rate

Respiratory function

  • Shortness of breath
  • Cough
  • Pulmonary x-ray
  • Increased sputum production

Neurologic/Sensory function

  • Altered mental status
  • Irritability
  • Restlessness
  • Somnolence

Visual appearance/labs

  • Skin color
  • Oximetry
  • Acid-base labs

Impaired Gas exchange Nursing Diagnosis[1,2]

Assessment of impaired gas exchange

  • Assess pulse oximetry
  • Assess cardiac function such as blood pressure and heart rate
  • Asses arterial blood gasses
  • Assess electrolytes blood pH
  • Assess use of central nervous system depressants
  • Inspect dependent body areas for edema with and without pitting
    • Pitting edema is generally obvious only after 10lbs weight gain

Rationale: 

  • Pulmonary edema may develop more rapidly, and immediate intervention is necessary
  • Use of central nervous system depressants may cause depression of respiratory center and cough reflex. This can result in hypoventilation and stasis of secretions with subsequent impaired gas exchange

Planning[1,2]

  • Prevent complications such as collapsed airway
  • Provide information about disease/prognosis, therapy needs, and prevention of recurrences
  • Client education

Risk for impaired gas exchange care note

Perform:

  • Auscultate breath sounds, noting crackles and wheezes
  • Measures to facilitate removal of pulmonary secretions such as suction, postural drainage, percussion and vibration
  • Consultation with appropriate health care providers if signs and symptoms worsen

Provide:

  • Instructions on copying such as effective coughing, deep breathing
    • Diaphragmatic breathing technique to promote greater movement of the diaphragm and decreased use of accessory muscles
    • pursed lip-breathing technique to cause mild resistance to exhalation, which creates positive pressure in airways. This can prevent airway collapse
  • Pillows to support elevated position and support for arms
  • Chest Physiotherapy
  • Supportive therapy to decrease chest and abdominal discomfort and pain if present
  • Assistance with positive airway pressure techniques-CPAP, BiPAP, PEP device
  • Support to decrease fear and anxiety
    • Assure breathing deeply will not dislodge tubes or cause wound opening

Administer:

  • Supplemental oxygen as indicated
  • Diuretics, bronchodilators, antibiotics, steroids, pain medications, anticoagulants

Monitor:

  • ABG’s
  • Blood pH
  • Pulse oximetry
    • In clients with abnormal cardiac index, research suggests pulse oximeter measurements may exceed actual oxygen saturation by up to 7%.
  • Reports of sudden extreme dyspnea/air hunger
  • Cognitive level
  • Blood pressure
  • Chest X-ray
  • WBC

Encourage:

  • Frequent position changes
    • Helps prevent atelectasis and pneumonia
    • Mobilized secretions
    • Aids lung expansion
  • Head and bed elevation 20-30 degrees, semi-Fowler’s position to reduce oxygen consumption and to promote maximal lung inflation
  • Use of spirometry every 1 to 2 hours
  • Engaging client in therapy regimen as it may enhance sense of control and cooperation with restrictions
  • Client to discontinue smoking
  • Gradual increase in activity as allowed and tolerated

Goals and Outcomes[1,2]

  • Client demonstrates adequate ventilation and oxygenation of tissue evidenced by ABGs and oximetry.
  • Client is free of symptoms of respiratory distress
  • Clients oximetry is within normal range
  • Client participates in treatment regimen within level of ability and situation
  • stabilized fluid volume with balanced intake and output
  • Breath sounds are clear
  • Vital signs within acceptable range

Post intervention evaluation/monitoring [1]

Monitor[1,2]

  • Cardiac rate and BP
  • ABGs
  • Oximetry
  • Unlabored respirations at 12-20 breaths/min
  • Electrolytes: sudden fluid shifts may lead to sodium and potassium imbalance/deficiency
  • Mental status

Future goals [1]

  • Absence of dyspnea
  • Normal depth and rate of respiration
  • Initiate supportive medication therapy
  • maintain healthy diet and weight goal

Prevention[1,2]

  • Discourage smoking
  • Adherence to medications

Supplemental material

Client case

Client is recovering from a bypass surgery 3 days ago and is currently admitted in the ICU. Client mentions that he is starting to experience shortness of breath and has a hard time taking a deep breath Client states he feels lightheaded while in bed and has a constant headache. Client has history of MI x 2, dyslipidemia and asthma

Questions: 

Based on the client case, what are the symptoms predictive of excess fluid volume?

Answer: SOB, difficulty breathing, lightheadedness, headache

When treating clients with impaired gas exchange, providers should avoid administration of:

  1. diuretics
  2. central nervous system depressants
  3. steroids
  4. anticoagulants

Preferred bed position to support lung function in clients with impaired gas exchange is

  1. legs elevated
  2. head and neck elevated 20-30 degrees
  3. arms supported
  4. prone position
  5. a and b
  6. b and c
  7. c and d

Clients with impaired gas exchange are at risk of

  1. Pulmonary edema
  2. Pulmonary congestion
  3. Altered mental status
  4. Increased heart rate
  5. All of the above

List at least 3 tips for preventing impaired gas exchange

  1. Stop smoking
  2. Promote cough and sputum clearing
  3. Engage in diaphragmatic and pursed lip breathing techniques
  4. Use medications as instructed
  5. Change bed positions often

References:

  1. Doenges, Marilynn E., et al. Nursing Care Plans: Guidelines for Individualizing Client Care. F.A. Davis, 2006.
  2. Haugen, Nancy, et al. Ulrich & Canale’s Nursing Care Planning Guides: Prioritization, Delegation, and Critical Reasoning. Elsevier, 2020.

Excess Fluid Volume

Posted on |

excess fluid volume nursing care plan

Introduction/Pathophysiology [1,2,3]

Reduced glomerular filtration, decreased cardiac output, increased antidiuretic hormone production and sodium/water retention can all lead to excess fluid volume/fluid overload. Excess fluid volume may be manifested by venous engorgement and edema formation. Peripheral edema begins in feet/ankles and ascends as failure worsens. Excess fluid volume often leads to pulmonary congestions and pulmonary edema. Excess Fluid Volume Nursing Diagnosis and the Excess Fluid Volume Nursing Care Plan are a crucial part of providing wholesome care for clients.

Causes[1,2]

  • Renal impairment
  • Decreased cardiac output
  • Heart failure
  • Increased antidiuretic hormone production
  • Diet high in sodium

Symptoms[1,2]

Subjective (client may report)

  • shortness of breath
  • weight gain
  • swelling
  • abdominal pain
  • nausea

Objective[1,2]

  • weight gain
  • decreased hemoglobin and hematocrit (Hct)
  • oliguria
  • edema
  • pleural effusion
  • orthopnea
  • changes in heart sounds
  • pulmonary congestion
  • JVD
  • positive hepatojugular reflux
  • respiratory distress, abnormal breath sounds
  • changes in mental status
  • BP changes
  • pulmonary artery pressure changes
  • pulmonary edema
  • altered electrolytes
  • anxiety, restlessness
  • increased central venous pressure
  • positive hepatojugular reflux
  • ascites
  • fluid and electrolyte imbalance

Risk factors[1,2]:

  • Hypertension
  • Recent/acute MI
  • Heart failure
  • Presence of kidney disease
  • Compromised regulatory systems
  • Excess sodium intake
  • Excess fluid intake

Intervention[1]

Assessment[1]

Collect client history, including risk factors and symptoms (objective and subjective data)

Cardiac Function:

  • BP and pulse
  • Central venous pressure (if available)

Respiratory function

  • Shortness of breath
  • Cough
  • Pulmonary x-ray

Neurologic/Sensory function

  • Altered mental status
  • Anxiety
  • Restlessness

Visual appearance/labs

  • Edema
  • Ascites
  • Anorexia
  • Skin surface/integrity
  • Urine color
  • Electrolyte imbalance (Na, K)
  • Decreased hematocrit
  • Changes in renal function tests

Excess Fluid Volume Nursing Diagnosis[1]

Assessment of client response to activity

  • Assess for distended neck and peripheral vessels
  • Inspect dependent body areas for edema with and without pitting
    • Pitting edema is generally obvious only after 10lbs weight gain
  • Note presence of generalized body edema; anasarca
  • Inspect skin surface/integrity
  • Bowel sounds
  • Measure abdominal girth, as indicated
  • Palpate abdomen
    • Note reports of right upper quadrant/tenderness

Rationale: 

  • Urine output may be scanty and concentrated because of decreased renal perfusion
  • Diuretic therapy may result in sudden fluid decrease-respite edema remaining
  • A weight gain of 5lbs represents about 2L of fluid excess
    • Weight gain 2% or greater in short time
  • Edema formation, slowed circulation and prolonged immobility can affect skin integrity
  • Pulmonary edema may develop more rapidly, and immediate intervention is necessary
  • Visceral congestion can alter gastric function

Planning[1,2]

  • Reduce fluid volume overload
  • Prevent complications
  • Provide information about disease/prognosis, therapy needs, and prevention of recurrences
  • Client education

Excess Fluid Volume Nursing Care Plan[1,2]

Perform:

  • Weight in daily- document changes in weight in response to therapy for edema
  • Frequent position changes in bed, elevate feet when sitting

Provide:

  • Fluid intake schedule if fluids are medically restricted, incorporate beverage preferences if possible
  • Frequent mouth care and ice chips
  • Assistance with Rotation of tourniquets/phlebotomy, dialysis, or ultrafiltration

Administer:

  • Diuretics, thiazides with potassium sparing agents, potassium supplements

Monitor:

  • Urine output, noting amount, color, time of day diuresis occurs
  • 24-hour intake and output (I&O)
  • Reports of sudden extreme dyspnea/air hunger
  • Cognitive level; anxiousness, panic, impending doom
  • Central venous pressure(CVP) if available
  • Blood pressure
  • Chest X-ray

Avoid:

  • large volume intravenous medications, consult pharmacist how to prevent excessive fluid administration of IV medications

Encourage:

  • Bed rest and sitting in semi-Fowler’ position during acute phases
  • Engaging client in therapy regimen as it may enhance sense of control and cooperation with restrictions
  • Verbalization of feelings regarding limitations
  • Small frequent meals to enhance digestion and prevent abdominal discomfort
  • Maintaining fluid/sodium restrictions
  • Consultation with dietitian

Goals and Outcomes[1,2]

  • Client demonstrates stabilized fluid volume with balanced intake and output
  • Breath sounds are clear
  • Vital signs within acceptable range
  • Stable weight
  • Absence of edema
  • Client understands fluid and dietary restrictions
  • BP within normal range
  • BUN and Hct within normal limitations
  • Usual mental status

Post intervention evaluation/monitoring [1]

Monitor[1]

  • Cardiac rate and BP
  • Renal function-BUN, CrCl
  • Liver function-AST, ALT
  • Weight
  • Edema
  • Electrolytes: sudden fluid shifts may lead to sodium and potassium imbalance/deficiency
  • Mental status
  • Intake and output
  • CVP readings

Future goals [1]

  • Prevent reoccurrence
  • Initiate supportive medication therapy
  • maintain healthy diet and weight goal

Prevention[1,2,3]

  • Promote healthy lifestyle
  • Educate about fluid and sodium intake

Supplemental material

Client case

Client presents to the emergency department with the chief complaint of peripheral edema, shortness of breath at rest and recent weight gain of about 10lbs. Client has history of stage 2 chronic kidney disease, heart failure, hypertension, is obese and drinks 3-4 alcoholic beverages per day.

Questions: 

Based on the client case, what are the symptoms predictive of excess fluid volume?

Answer: weight gain, SOB, peripheral edema

When treating clients experiencing fluid excess volume, providers should avoid administration of:

  1. diuretics
  2. thiazides
  3. high volume IV drugs
  4. Potassium supplements

Excess in fluid volume is often associated with:

  1. Decrease in hemoglobin
  2. Increase in hemoglobin
  3. Increase in CrCl
  4. Weight loss

Clients with edema are at risk for:

  1. Altered gastric function
  2. Pulmonary congestion
  3. Impaired skin integrity
  4. Altered mental status
  5. All of the above

List at least 3 tips for preventing fluid overload

  1. Decrease the amount of sodium in your diet
  2. Eliminate alcoholic beverages
  3. Treat underlying conditions, high blood pressure
  4. Take your medications daily
  5. When choosing fluids, choose water and unsweetened beverages

References:

  1. Doenges, Marilynn E., et al. Nursing Care Plans: Guidelines for Individualizing Client Care. F.A. Davis, 2006.
  2. Haugen, Nancy, et al. Ulrich & Canale’s Nursing Care Planning Guides: Prioritization, Delegation, and Critical Reasoning. Elsevier, 2020.
  3. Assis, Cinthia Calsinski de, and Alba Botura Leite de Barros. “Nursing Diagnoses in Clients With Congestive Heart Failure.” Wiley Online Library, John Wiley & Sons, Ltd, 25 July 2008, onlinelibrary.wiley.com/doi/abs/10.1111/j.1744-618X.2003.001.x.

Activity Intolerance

Posted on |

nursing intervention for activity intolerance

Introduction/Pathophysiology [1,3]

Activity intolerance can be described as insufficient physiological or psychological energy to complete required or desired daily activities. Activity intolerance is a common side effect of heart failure and can be related to generalized weakness and difficulty resting and sleeping. A contributing factor is often tissue hypoxia caused by decreased cardiac output.  The International Journal of Nursing identified activity intolerance in 100% of clients with NYHA classes I-IV congestive heart failure as well as activity intolerance is one of the most common diagnoses identified by nurses. Nursing intervention for activity intolerance is an important part of wholesome client care.

Causes[1,2]

  • coronary disease
  • decreased cardiac output
  • hypertension
  • congenital problems
  • congestive heart failure
  • cardiac arrhythmias/dysrhythmias
  • structural abnormalities
  • myocardial ischemia and myocardial infarction

Symptoms[1,2]

Subjective (client may report)

  • fatigue
  • abnormal heart rate or blood pressure in response to activity
  • exertional discomfort
  • dysrhythmias
  • dyspnea with exertion
  • chest pain

Objective[1]:

  • Abnormal blood pressure response to activity
    • excessive rise in blood pressure-systolic>180 or diastolic >110 mmHg
    • excessive hypotension-drop in blood pressure of 10 mm Hg from from baseline blood pressure
  • Abnormal heart rate in response to activity
    • Inappropriate bradycardia- drop in heart rate 10 beats per minute
    • Increased heart rate > 100 beats per minute
  • EKG changes reflecting arrhythmias or ischemia
  • Excess fluid volume/edema-provide nursing intervention for fluid volume excess

Risk factors[1]:

  • History of hypertension
  • Recent/acute MI
  • Previous episodes of HF
  • Valvular heart disease, cardiac surgery
  • Smoking
  • Presence of respiratory disease
  • Inexperience with activity

Intervention[1]

Assessment[1]

Collect client history, including risk factors and symptoms (objective and subjective data)

Cardiac Function:

  • Chest pain
  • Abnormal heart rate in response to activity
  • Increase in rate of 20 BPM above resting rate
  • Rate not returning to baseline level within 3 minutes after stopping activity

Respiratory function

  • Wheezing
  • Cough
  • Tachypnea

Neurologic/Sensory function

  • Fatigue
  • Asthenia

Visual appearance/labs

  • Fatigue
  • Asthenia
  • Diaphoresis
  • Edema

Nursing diagnosis[1]

Assessment of client response to activity

  • note pulse rate more than 20 beats/min faster than resting rate; marked increase in BP during/after activity (systolic increase of 40 mm Hg or diastolic pressure increase of 20 mm Hg); dyspnea or chest pain; excessive fatigue and weakness; diaphoresis; dizziness or syncope.

Rationale:

  • The stated parameters are helpful in assessing physiological responses to the stress of activity and, if present, are indicators of overexertion.

Planning[1,2]

  • Improve myocardial contractility/systemic perfusion
  • Reduce fluid volume overload
  • Prevent complications
  • Provide information about disease/prognosis, therapy needs, and prevention of recurrences
  • Provide activity intolerance care plan for client
  • Improve edema-provide nursing interventions for fluid volume excess

Activity Intolerance Nursing Care plan[1,2]

Perform:

  • Actions to maintain adequate cardiac output

Provide:

  • Support with Vagal maneuvers
  • Assistance with cardioversion or defibrillation if performed
  • Calm environment-limit number of visitors
  • Tips for energy saving techniques (e.g., using chair when showering, brushing teeth, combing hair)

Administer:

  • Supplemental oxygen
  • Antidysrhythmic agents, Anticholinergic agents, pain medications if needed

Monitor:

  • Oxygen levels
  • Blood pressure
  • Heart rate

Encourage:

  • Gradual increase in activity as allowed and tolerated
  • Measures to promote sleep

Goals and Outcomes[1,2]

  • Ability to participate in activities of daily living with decreased incidence of dyspnea, chest pain, diaphoresis, dizziness and changes in vital signs
  • Client reported increase in activity tolerance
  • Client demonstrates decrease in physiological signs of intolerance
  • Plan in place to meet needs after discharge
  • Provide activity intolerance care plan for home/discharge

Post-Nursing intervention for activity intolerance evaluation/monitoring [1]

Monitor[1]

  • Cardiac rate and BP

Future goals [1]

  • Dysrhythmia controlled or absent
  • Pulse oximetry within acceptable range/ free of signs of respiratory distress
  • Client meets all self-care needs
  • Client demonstrates increase in activity tolerance

Prevention[1,2,3]

  • Promote healthy lifestyle
  • Encourage smoking cessation
  • Educate about tips to conserve energy
  • Provide activity intolerance nursing care plan

Supplemental material

Client case

Client presents to the ambulatory clinic with the chief complain of constant tiredness, shortness of breath when engaging in activities of daily living and mild-moderate chest pain when having to climb the stairs at home. Client also reports trouble sleeping and waking up restless. Client’s current blood pressure is 135/75 and heartbeat is 68 bpm. Client has a history of asthma, is overweight and currently smokes ½ ppd.

Questions:

Based on the client case, what are the symptoms predictive of activity intolerance?

Answer: tiredness, shortness of breath when engaging in AODL, trouble sleeping, chest pain, restlessness

Changes in what value during exercise is indicative of activity intolerance?

  1. diastolic pressure increase of 10 mm Hg from baseline
  2. pulse rate more than 5 beats/min faster than resting rate
  3. rise in systolic BP >140
  4. systolic pressure increases of 40 mm Hg from baseline

What medications are appropriate to treat acute symptoms of activity intolerance with chest pain?

  1. Antidysrhythmic agents
  2. Anticholinergic agents
  3. pain medications
  4. A and C
  5. C and B
  6. All of the above

The International Journal of Nursing identified that activity intolerance is present in what percentage of clients with NYHA classes I-IV congestive heart failure?

  1. 20%
  2. 40%
  3. 60%
  4. 80%
  5. 100%

List at least 3 tips for conserving energy during AODL

  1. Using chair when showering
  2. Using the elevator when possible
  3. Using an electric shopping card
  4. Taking advantage of delivery services
  5. Using a wheeling card when moving items

References:

  1. Doenges, Marilynn E., et al. Nursing Care Plans: Guidelines for Individualizing Client Care. F.A. Davis, 2006.
  2. Haugen, Nancy, et al. Ulrich & Canale’s Nursing Care Planning Guides: Prioritization, Delegation, and Critical Reasoning. Elsevier, 2020.
  3. Assis, Cinthia Calsinski de, and Alba Botura Leite de Barros. “Nursing Diagnoses in Clients With Congestive Heart Failure.” Wiley Online Library, John Wiley & Sons, Ltd, 25 July 2008, onlinelibrary.wiley.com/doi/abs/10.1111/j.1744-618X.2003.001.x.

Decreased Cardiac Output

Posted on |

decreased cardiac output nursing diagnosis

Introduction/Pathophysiology [1,2]

Cardiac output (CO), expressed in L/min, is the volume of blood in the heart pump in one minute, depending on the heart’s rate, contractility, preload and afterload. Cardiac output is directly influenced by the heart rate and stroke volume. Regulation of cardiac output includes autonomic nervous system, endocrine and paracrine signaling. Cells, tissues and organs rely on the heart pumping the blood to deliver nutrients. Decreased cardiac output may result in insufficient blood supply and compromise vital reactions. This can result in transition towards anaerobic metabolic pathways which lead to production of lactic acid, reduced cellular pH, enzyme denaturation, and altered membrane potential. If not addressed, decreased cardiac output can lead to tissue and organ damage. Most common diagnoses associated with decreased cardiac output is heart failure. Heart failure (HF) is defined as failure of either the left and/or right chambers of the heart resulting in insufficient output to meet tissue needs resulting in pulmonary and systemic vascular congestion. In addition, blood pooling in the ventricles can increase the risk for stroke and pulmonary embolism. Decreased cardiac output nursing care plan and nursing interventions for decreased cardiac output are crucial steps to prevent possible life-threatening complications.

Causes[1]

Impaired cardiac function and decreased cardiac output can be caused by:

  • coronary disease
  • hypertension
  • congenital problems
  • tamponade
  • medications such as vasopressor and calcium channel blockers
  • pericardial effusions
  • emboli
  • congestive heart failure
  • shock
  • cardiac arrhythmias/dysrhythmias
  • genetic diseases
  • structural abnormalities
  •  myocardial ischemia and myocardial infarction

Symptoms[1]

Subjective (client may report)

  • fatigue
  •  exhaustion progressing throughout the day
  •  exercise intolerance
  • insomnia
  • chest pain/pressure with activity
  •  dyspnea at rest or with exertion

Objective[1]:

  • Increased heart rate
  • Altered myocardial contractility
  • inotropic changes
  • Diagnosis for Atrial Fibrillation
  • History of decreased cardiac output nursing diagnosis
  • irregular heart rate
  • Changes in rhythm and electrical conduction
  • Cardiac dysrhythmia
  • Structural heart changes
    • valvular defects
    • ventricular aneurysm
  • Jugular vein distention
  • Extra heart sounds
  • Decreased urine output
  • Diminished peripheral pulses
  • Cool, ashy skin; diaphoresis
  • Wheezes
  • Tachypnea
  • Nail beds pale or cyanotic, with slow capillary refill
  • Orthopnea
  • Crackles
  • Liver engorgement
  • Edema
  • Lower extremity swelling
  • Mental status change
  • Cough
    • Dry/hacking/nonproductive
    • gurgling with/without sputum
  • Restlessness, anxiety
  • Lethargy
  • Vital signs change with activity
  • Breath sounds diminished, bibasilar crackles

Risk factors[1]:

  • History of hypertension
  • Recent/acute MI
  • Previous episodes of HF
  • Valvular heart disease, cardiac surgery
  • Endocarditis
  • Systemic lupus erythematosus (SLE)
  • Anemia
  • Septic shock
  • Swelling of feet, legs, abdomen,
  • Diet high in salt/processed foods, fat, sugar, and caffeine
  • Smoking

Nursing interventions for decreased cardiac output[1]

Assessment[1]

Collect client history, including risk factors and symptoms (objective and subjective data)

Cardiac function

  • Increased HR
  • Altered myocardial contractility
  • Diagnosis for Atrial Fibrillation
  • Structural changes
  • Jugular vein distention
  • Extra heart sounds
  • Diminished peripheral pulses

Neurologic/Sensory function

  • Mental status change
  • Restlessness
  • Anxiety
  • Lethargy

Respiratory function

  • Breath sounds
  • Wheezing
  • Cough
  • Tachypnea
  • Orthopnea

Visual appearance/labs

  • Skin (cool/ashy)
  • Nail beds
  • Edema
  • Decrease Urine Output
  • Lower extremity swelling

Decreased Cardiac Output Nursing diagnosis[1]

Diagnostic testRationale
ECGVentricular or atrial hypertrophy, axis deviation, ischemia, and damage patterns may be present. Dysrhythmias, e.g.,tachycardia, atrial fibrillation, conduction delays, especially left bundle branch block, frequent premature ventricular con-tractions (PVCs) may be present. Persistent ST-T segment abnormalities and decreased QRS amplitude may be present.
Chest X-rayMay show enlarged cardiac shadow, reflecting chamber dilation/hypertrophy, or changes in blood vessels, reflecting increased pulmonary pressure. Abnormal contour, e.g., bulging of left cardiac border, may suggest ventricular aneurysm.
Sonograms echocardiogram

Doppler and transesophageal echocardiogram

May reveal enlarged chamber dimensions, alterations in valvular function/structure, the degrees of ventricular dilation and dysfunction.
Heart scanMeasures cardiac volume during both systole and diastole, measures ejection fraction, and estimates wall motion.
Exercise or pharmacological stress myocardial perfusionDetermines presence of myocardial ischemia and wall motion abnormalities.

Positron emission tomography (PET) scan. Sensitive test for evaluation of myocardial ischemia/detecting viable myocardium.

Cardiac catheterizationAbnormal pressures are indicative and help differentiate right- versus left-sided heart failure, as well as valve stenosis or insufficiency. Also assesses patency of coronary arteries. Contrast injected into the ventricles reveals ab-normal size and ejection fraction/altered contractility. Transvenous endomyocardial biopsy may be useful in some clients to determine the underlying disorder, such as myocarditis or amyloidosis.
Liver enzymesElevated in liver congestion/failure
Digoxin and other cardiac drug levelsDetermine therapeutic range and correlate with client response.
Bleeding and clotting timesMay be altered because of fluid shifts/decreased renal function, diuretic therapy.
Electrolytes:May be altered because of fluid shifts/decreased renal function, diuretic therapy
Pulse oximetryOxygen saturation may be low, especially when acute HF is imposed on chronic obstructive pulmonary disease (COPD) or chronic HF.
Arterial blood gases (ABGs)Left ventricular failure is characterized by mild respiratory alkalosis (early) or hypoxemia with an increased PCO2(late).
BUN/creatinineElevated BUN suggests decreased renal perfusion. Elevation of both BUN and creatinine is indicative of renal failure.
Serum albumin/transferrin:May be decreased as a result of reduced protein intake or reduced protein synthesis in congested liver.
Thyroid studiesIncreased thyroid activity suggests thyroid hyperactivity as precipitator of HF.
Complete blood count (CBC)May reveal anemia, polycythemia, or dilutional changes indicating water retention. Levels of white blood cells (WBCs) may be elevated, reflecting recent/acute MI, pericarditis, or other inflammatory or infectious states.
ESR:May be elevated, indicating acute inflammatory reaction

Planning[1]

  • Improve myocardial contractility/systemic perfusion
  • Reduce fluid volume overload
  • Prevent complications
  • Familiarize other providers with the decreased cardiac output nursing care plan to ensure proper collaboration
  • Provide information about disease/prognosis, therapy needs, and prevention of

Nursing actions[1]

Perform
  • Auscultate apical pulses
  • Assess heart rate and rhythm
  • Document dysrhythmias
  • Palpate peripheral pulses
  • Skin inspection for pallor, cyanosis
  • assist with physical care
  • Elevate legs, avoiding pressure under the knee
  • Check for calf tenderness
Provide
  • Quiet environment
  • Help prevent stress
Administer
  • Supplemental oxygen
  • IV fluids/electrolytes
  • Medications as indicated (diuretics, vasodilators-nitrates, arteriodilators-hydralazine, combination drugs-prazosin, ACE inhibitors, digoxin, inotropic agents, beta blockers, morphine, anxiety agents, sedatives, anticoagulants)
Monitor
  • Heart sounds
  • Blood pressure
  • Heart rate
  • Urine Output
Encourage
  • Rest
  • Active/passive exercises
  • Verbalization of clients’ concerns and provide the client with decision-making opportunities

Goals and Outcomes[1]

  • Cardiac output adequate for individual needs
  • Complications prevented/resolved
  • Optimum level of activity/functioning attained
  • Disease process/prognosis and therapeutic regimen understood by
  • Plan in place to meet needs after discharge
  • Provide at home care plan decreased cardiac output

Post intervention evaluation/monitoring[1]

Monitor[1]

  • Cardiac rate and BP, ECG, chest x-ray, central venous pressure if available
  • Urine output and dark/concentrated urine
  • Mental status and changes in sensorium
  • Check for calf tenderness
  • Inspect skin
  • Lab results: BUN, creatinine, AST, LDH, PT, aPTT

Future goals [1]

  • Dysrhythmia controlled or absent
  • Pulse oximetry within acceptable range/ free of signs of respiratory distress
  • Client meets all self-care needs
    • Care plan decreased cardiac output shared with primary care provider
  • Client demonstrates increase in activity tolerance

Prevention [1]

  • Educate about the diagnosis, symptoms and treatment
    • Provide decreased cardiac output nursing care plan adjusted for home care
  • Promote healthy lifestyle and diet
  • Promote healthy lifestyle and diet
  • Provide plan to decrease stress and prevent anxiety

Supplemental material

Client case

Client presents to the ER with the chief complaint of fatigue and shortness of breath when engaging in mild physical activity. Client has also noticed a recent weight gain and swelling in ankles. Client’s current blood pressure is 146/80 and heartbeat is 70 bpm. Client has a history of atrial fibrillation, hypertension, dyslipidemia and type 2 diabetes.

Questions:

Based on the client case, what are the symptoms predictive of heart failure?

Answer: shortness of breath, fatigue, edema

Changes in what lab value is indicative of renal failure in clients with decreased cardiac output?

  • a. AST
  • b. BUN
  • c. Troponin
  • d. VHDL

What chronic medications should be generally avoided in clients with known diagnosis of heart failure?

  • a. ACE inhibitors
  • b. Beta blockers
  • c. Calcium channel blocker
  • d. morphine

Which exam can measure cardiac volume during systole and diastole?

  • a. Chest X-ray
  • b. ECG
  • c. Heart scan
  • d. Sonogram

Units that represent Cardiac Output are:

  • a. L
  • b. L/min
  • c. m3
  • d. min

References

  1. Vincent JL. Understanding cardiac output. Crit Care. 2008;12(4):174. doi:10.1186/cc6975
  2. King J, Lowery DR. Physiology, Cardiac Output. In: StatPearls. Treasure Island (FL): StatPearls Publishing; September 15, 2020.