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Mach 1, 2017
Problem:
Impaired comfort – related to- acute pain in the femoral artery from LVAD placement procedure- as
evidence by - patient states pain due to procedure in the femoral artery, observed patient grimacing
(Lippincott Advisor for Education, 2017).
Intervention 3
Educate the patient on what causes the pain and
how long the pain can be expected to last Patient has verbalized that she
(Lippincott Advisor for Education, 2017). Nurse understands if pain doesn’t reside to the
will educate patient on the specific reason the 2-3/10 on the pain scale in 20min-1hr
pain is occurring when it occurs and the safety after administration of pain medication
net of how fast the pain should go away. (aspirin)- to let the nurse know or call the
physician when needed.
Patient has taught her family (Spanish
speaking) about why she is experiencing
pain i.e. post surgery – placement of
catheter, etc.
Rationale:
Providing this education to the patient during
hospitalization could help prevent further
complications that could be potentially more
severe. The patient will gain the knowledge to
know what is going on in their body and will help
the patient to inference when going to the ED is
necessary.
Evaluation: Summarize patient progress toward outcome objectives:
1. Patient has verbalized throughout hospitalization upon assessment that pain management
has been controlled within the 2-3/10 scale – averaging at about a 2 every day
2. Patient has explored and will continue to use alternative therapies that are beneficial to
positive outcomes including: music therapy, distraction, and breathing exercises.
3. Patient is able to verbalize why the pain is occurring in the body and the time increments that
pain should not exceed with proper management.
Problem:
Risk for decreased peripheral tissue perfusion – related to - Hx of various cardiac diseases (issues); sedentary
during hospitalization (Lippincott Advisor for Education, 2017)
Predicted Outcome Objective (s): The patient will…
Pt will work with physical therapist at least once a day to increase physical activity - increasing blood flow. Pt.
will be educated on protocols to reduce workload on the heart until transplant.
Nursing Strategies Patient Response/Family Response
Intervention 1
Reinforce and assist the patient with exercises to Patient is compliant and willing to always
promote blood flow (Lippincott Advisor for work with PT and really enjoys it and
Education, 2017). Patient will work with Physical looks forward to PT time during the day.
therapist (schedule recommended by PT) on Patient has been working with PT daily
physical activities that interest the patient to
Shelby Furubayashi
Mach 1, 2017
increase blood flow to the peripheral tissues. and enjoys it. She has learned physical
activities that are beneficial to her and
Rationale:
that are accessible for her to perform.
Increasing physical activity can increase the blood
flow to the peripheral parts of the body. Active
range of motion also can help promote the flow
of blood to and from the heart and the
throughout the body.
Intervention 2
Provide prophylaxis for deep vein thrombosis and
monitor for response (Lippincott Advisor for Patient has been wearing compression
Education, 2017). By educating patient and stockings every day when in bed; patient
encouraging patient to apply some techniques to will also raise legs for about 2 hrs every
decrease the occurrence of DVT can help the day when in bed.
peripheral perfusion of blood continue to move. Patient also has been doing leg exercises
Rationale: with PT to help blood flow and to
Enforcing and educating patients on why these decrease the chances of DVT. Patients
activities to prevent DVT is important such as: verbalizes that doing such activities helps
applying compression stockings, staying active her fill more alert and awake with the
(ambulation), raising legs above the heart once a increased blood flow.
day, etc. helps prevent deep vein thrombosis
from occurring which keeps the blood flowing
and the ability to perfuse to the body.
Intervention 3
Assess the patient's peripheral pulses and
capillary refill every 2 hours to assure peripheral We assess patient’s peripheral pulses
blood flow is occurring (Lippincott Advisor for against her apical pulse along with
Education, 2017). Observing is prophylactic and capillary refill every 2 hrs. Patient has
required to make sure the heart is properly been able to learn how to check her own
pumping the blood to the rest of the body. pulses and capillary refill that will be
Rationale: beneficial upon discharge.
Assessing the patient’s capillary refill and Patient and family have become very
peripheral pulses helps monitor that blood is compliant in assessing peripheral pulses
reaching the patient’s extremities and the blood and capillary refill. Patient has taught
is properly flowing throughout the body. This is a family and now it’s kind of like a game.
good warning sign that the entire body is not This will be beneficial to the patient when
getting adequate amounts of blood. at home.
assess the peripheral blood flow to farthest part of the extremities. Pulse has been present x
RRR in all 4 extremities during hospitalization. Pt also developed the skill of assessing own
capillary refill and pulses that will be beneficial upon discharge.
Problem:
Risk for Falls – related to - Postoperative recovery period and vascular disorders. (Lippincott Advisor for
Education, 2017)
Predicted Outcome Objective (s): The patient will…
Patient will call for assistance during hospitalization - postop to help education and balance (Lippincott).
Patient upon discharge will not have any falls during hospitalization and patient and family will be educated
on proper technique to reduce falls.
Nursing Strategies Patient Response/Family Response
Intervention 1
Assist the patient with mobility (getting out of
bed, ambulation) (Lippincott Advisor for Patient has been very compliant with
Education, 2017). Patient will use call light for using the call light to have assistance
assistance out of bed during hospitalization. upon transfer.
Rationale: Patient’s family has been with patient to
Using the call light and having assistance or even PT and has learned how to assist properly
observation on transferring following a in optimal transfer.
procedure - benefits the patient and nurse on Patient has begun to gain optimal
teaching skills and safety precautions. This balance and gait but still calls for
prevents falls from occurring that could cause assistance upon transfer.
further complications. Reassurance of safety is
always necessary for patients in the hospital
environment.
Intervention 2
Obtain a physical therapy consult, as needed
(Lippincott Advisor for Education, 2017). Physical Patient has been working with PT every
therapy once a day could benefit the patient on day that she thoroughly enjoys. Patient
increasing strength and proper techniques to has gained more strength postop and
decrease the risk of falls. patient and family have been shown and
Rationale: have practiced proper transferring skills.
Physical therapy can help the patient gain Such as: weight a minute after sitting up
techniques to help transferring and positioning to stand up, make sure non skid socks are
better - causing less safety hazards such as falls. on, call for assistance if feeling drowsy or
Spending adequate time with PT could also uneasy.
increase the patient’s strength that is needed to Patient has also gained strength in her
keep balance, coordination, and stability during body by doing exercises such as walking
transitions. up flights of stairs, or doing leg exercises
in a chair with LVAD beside her.
Shelby Furubayashi
Mach 1, 2017
Intervention 3
Discuss measures the patient and family can take Patient and family have met with
at home to alter the environment to promote educators and OT to help make the home
safety and prevent falls from occurring environment more accessible for the
(Lippincott Advisor for Education, 2017). Patient patient that is coming home postop and
and family will be educated on safety measures with a new external device (LVAD).
that will be helpful upon discharge during the Patient and family have learned together
week postop with the interdisciplinary team. the importance of keeping the home a
Rationale: safe environment and can keep each
Having the patient and family be educated on other accountable for keeping it this way.
techniques to decrease fall hazards will help the
transition upon discharge in the family’s life.
Learning together can also optimize the safety
and relationships within the family to increase fall
precautions.
References
Lippincott Advisor for Education. (2017). Lippincott Advisor for Education. Retrieved March 1, 2017,
from http://advisor-edu.lww.com/lna/home.do