Prioritization of Nursing Problems

Prioritization of Nursing problems

Nursing problem Ineffective Cardiopulmonary Tissue Perfusion

Cues Subjective: >Report of dyspnea even at rest >Palpitation >Chest pain at 9/10 pain scale

Objective: >Use of accessory muscles when  breathing* >Poor capillary refill (>5s)* >Pale skin >Pale mucous membrane >↓Hgb of 139 g/L >Hct of 0.42 >041510: 2-D Echo result shows Mild Tricuspid Regurgitation and impaired diastrolic relaxation of Left ventricle* >RR of 23cpm* PR of 104bpm* BP of 160/80mmHg

Acute pain

Subjective:

Justification It is prioritized hence as reference Maslow’s Hierarchy such it falls under   physiological needs, such it must be met at least minimally to maintain life, as these needs are the most basic in the hierarchy as these are one of the most essential to life therefore it gained the highest priority ;Carol Taylor(2009) , thus the main problem is the disease condition which is Coronary Artery Disease which is the oxygenated blood distribution to the circulation is compromised , in relevance with that oxygen is the essential to all needs because cells needs oxygen for  survival . Thus solving this nursing can alleviate or  decrease the gravity of the other  succeeding nursing problems hence those are the signs and symptoms of the disease condition which can chiefly addressed  by intervening first at in this nursing  problem

This nursing problem is also falls under   physiological needs on Ms low’s -Pain scale of 9/10 for Chest pains Hierarchy of needs but in a way it is Objective: subsequent to the first nursing problem . such the pain is result of omission to - Exhibits facial grimace upon palpation of  intervene with the prioritized problem . the abdomen. Pain hinder or limits physical activity

NURSING CARE PLANS PROBLEM #1 Ineffective (Cardiopulmonary) Tissue Perfusion Assessment Nursing Diagnosis Goals & Objectives

Nursing Interventions

Rationale

Evaluation

Subjective: >Report of dyspnea even at rest >Palpitation >Chest pain at 9/10 pain scale Objective: >Use of accessory muscles when breathing* >Poor capillary refill (>5s)* >Pale skin >Pale mucous membrane >↓Hgb of 139 g/L >Hct of 0.42 >041510: 2-D Echo result shows Mild Tricuspid Regurgitation and impaired diastrolic relaxation of Left ventricle* >RR of 23cpm* PR of 104bpm* BP of 160/80mmHg

Ineffective Cardiopulmonary Tissue Perfusion secondary to impaired transport of  oxygen (NANDA, 2009)

After 30 minutes of  nursing intervention, these should manifest:

>Encourage quiet, restful and peaceful environment

*To conserve energy & ↓ body tissue O2 demand.

>Relief of dyspnea without the use of  accessory muscles >↓ Chest Pain Scale from 6 to 1-4/10 >Skin normal in color  >have a stable vital signs of BP=100/70140/80mmHg PR=60-100bpm RR=12-20cpm

>Inform client to avoid activities; like, straining at stool

>Relief from dyspnea and *It increases  breathing normally without t cardiac workload use of accessory muscles >Chest Pain scale of 4/10 >Skin pale in color  *Hypertension >Vital Signs of 130/80mmH can damage blood 93bpm and 18 cpm vessel & organ function *To decrease tension level

>Always monitor  the blood pressure >Encourage use of  relaxation techniques >Position patient in semi to high fowler’s position >Encourage deep   breathing exercises

*To promote optimal lung expansion & decreases cardiac workload

*To promote lung >Educate the expansion  patient about * to enable for the his/her medication treatment to have regimen( e.g. taking of   better outcome or  vasodilators) result

After 3 hrs of nursing intervention, the goal was  partially met as manifested b

PROBLEM #2 Acute pain

Assessment

Nursing Diagnosis

Subjective: -Pain scale of  9/10 for  abdominal pains Objective: . - Exhibits facial grimace upon palpation of the abdomen. -Shows signs of  Irritability - Restlessness

Chronic pain related to in adequate as manifested by the Pain scale of 9/10 for  chest pains.

(NANDA,2009)

Goals and Objectives

Nursing interventions

Independent: -Provide comfort measures Short Term: >Within 15-30 min such as use of pillows under  extremities and periodic of intermediate wound cleaning on affected nursing area. intervention - Encourage and assist client - Verbalize to do deep breathing reduction/ exercises. relief of pain in the - Teach client and significant chest other about the non>Within 8 hours pharmacologic ways to shift with average lessen the pain. - Instruct client to report any of  improvement/exacerbation in nursing interventions, the pain experience. - Encourage verbalization of  patient will be feelings about the pain. able to: - Physical Examination: - Feel and palpate Periodic auscultation of the chest without abdomen for bowel sounds facial Inspection and Palpation for  grimace and masses and tenderness.

moaning. - Recite and demonstrate some nonpharmacologic ways to lessen pain.

Dependent: - Administer medications, particularly analgesics, as prescribed. - Assist with laboratory/diagnostic studies

Rationale

Evaluation

After 8 hours shift of nursing intervention the patient verbalize Deep breathing reduction of  exercises pain, goal is half  contribute to relief  met due to the of pain patient needs further  To maximize examination opportunities for  and medical self-control over  pain intervention. To promote relief  and wellness.

manifestations. Only the client can  judge the level and distress of pain; pain management should be a team approach that includes the client. Necessary for  management of  underlying and

PROBLEM #3 Impaired physical mobility Assessment

Nursing Goals & Objectives Intervention Diagnosis Independent: Subjective : Long term: Impaired 1. Determine  physical After 4 days of nursing degree of  Objective: mobility intervention, client will immobility related to  be able to ↑ physical • Limited ability 2. Observe disease mobility and difficulty to movement when Expected outcome :  perform gross motor  condition client is unaware 3. Support ( Coronary • skills Demonstrate affected part Artery resumption of  • General body with pillows Disease) activities weakness 4. Give rest manifested by • Participate in • Slowed  periods to limitation of  ADL’s movement activities movement 5. Encourage • Maintain or ↑ and work  adequate fluids muscle control and right diet as Short term: necessary to the After 8 hrs of nursing client intervention, client will  be able to participate in therapeutic regimen Expected outcome : • Verbalize understanding of  the situation • Verbalization of  understanding the therapy • Able to  participate in the interventions (NANDA, rendered by the 2009) nurse

Rationale Independent: 1. To establish comparative  baseline 2. To note any incongruenc e with the reports of  abilities 3. Reduce risk of   pressure ulcers 4. To help reduce fatigue and O2 demand 5. ↑ energy  production

Evaluation Long term goals met : Client is able to ↑physical mobility as evidenced by resumption of  activities, participation in his ADL’s Short term goals met: The client is able to participate on the therapeutic regimen as evidenced by verbalization of understanding of the situation, therapy, and he is able to participate in the interventions rendered  by the nurse