Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

Subjective:

Daughter reported patient exhibited “mood swings” and periods of “confusion.”  Client expressed she didn’t want to move “anymore than she has to.”

Hx of DM II, CAD

Objective:

Temp:  101.0

Basilar rales bilaterally

Elevated BP (145/86)

Elevated HR (110)

Client is in atrial fibrillation w/ rapid ventricular response

EKG findings of inferior infarction and left axis deviation

Decreased grips/weakness on left side

Decreased urine output (0 ml/10 hours)

Elevated potassium level of 5.3

Elevated BUN (41)

Elevated Creatinine (1.73)

Post-CVA

Problem

Ineffective tissue perfusion (cardiac, renal, cerebral)

Long Term:

Client will verbalize knowledge of their treatment regimen, including appropriate exercise and medications, their actions and possible side effects by [date] at 16:00.

-Assess current level of knowledge r/t treatment regimen, exercise and medications.

-Aggressively counsel the patient to stop smoking and refer to the physician for medications to support nicotine withdrawal and a smoking withdrawal program.  There is a 45% smaller hyperemic vascular responsive in smokers than non-smokers (Noble, Voegeli, McClough, 2003).

-Teach client the treatment regimen, exercise goals and plan, and medication regimen along with actions and side effects.

All interventions to be evaluated [date], 16:00.

R/T

Decreased hemoglobin concentration in blood, exchange problems, impaired transport of oxygen and interruption of blood flow secondary to subarachnoid hemorrhage

Short Term:

Client will demonstrate adequate tissue perfusion AEB blood pressure, pulse rate and rhythm within normal parameters for client; strong peripheral pulses, and ability to tolerate activity without dyspnea, syncope or chest pain, and increased urine output by [date] at 16:00.

-Monitor for s/s of heart failure and decreased cardiac output; listen to heart sounds, lung sounds; note symptoms.

-If symptoms of renal failure, cardiac failure or another CVA occur, notify the physician immediately.

-Monitor peripheral pulses.  If there is a new onset of loss of pulses with bluish, purple or black areas and extreme pain, notify the physician immediately.

-Monitor neuro status frequently

-Administer oxygen via nasal cannula to increase O2 to at least 92% as ordered

AEB:

Altered mental status, behavior changes, changes in papillary reactions, difficulty in swallowing, left side extremity weakness, right side hemiparesis, altered BP outside of acceptable parameters, oliguria (0 ml/10 hr), elevated BUN (41), elevated creatinine (1.73), dysrhythmias, altered respiratory rate (24).