CUES/EVIDENCES Subjective: Verbalized that before admission, she feels sudden chest pain after doing her house

e chores that is relieved by rest Verbalized that she feels tired and uncomfortable staying in bed at times and even feels lazy to stand up to go to the toilet Feels dizzy when rising from bed

NURSING DIAGNOSIS Ineffective tissue perfusion: cardiopulmonary, related to interruption of myocardial blood flow secondary to ischemic heart disease

OBJECTIVES Within our 2 days care, our client will reestablish adequate cardiac perfusion as evidenced by: Demonstrate adequate perfusion as individually appropriate (e.g., skin warm and dry, peripheral pulses present and strong, vital signs within patients normal range, balanced I&O, absence of edema, free of pain/discomfort) Verbalized understanding of condition, therapy regimen, side effects of medication, and when to contact healthcare provider. Demonstrate

INTERVENTIONS Independent: Monitor vital signs

RATIONALE

Provides comparison with current findings (baseline data) (Jean Watsons The Philosophy and Science of Caring: Nursing is concerned with promoting health, preventing illness, caring for the sick, and restoring health) To note degree of impairment/organ involvement (Faye Glenn Abdellahs Concept of Twenty One Nursing Problems: To promote safety)

Objective: Vital Signs: - T=37 C afebrile - PR= 64 bpm weak - RR= 22 cpm regular with slight use of accessory muscle - BP=110/70 mmHg

Note for any sensory or motor changes, mental status

To promote circulation/venous drainage (Florence Nightingales Environmental Theory: Focuses on changing and manipulating the

Capilliary refill- less than 3 seconds Pale skin and mucous membranes of the mouth and palpebral conjunctiva Nail beds are also slightly pale X-RAY Result reveals calcified aortic knob; atheromatous aorta Hgb: 11 g/dl Troponin T (+) ECG 12- lead result reveals sinus rhythm with anterior lateral wall with myocardial ischemia

behaviours/ lifestyle changes to improve circulation (eg. Relaxation techniques, exercise, dietary programs)

Elevate HOB (eg. 10) and maintain head/neck in midline or neural position

environment in order to put the patient in the best possible condition for nature to act) To increase urine flow and to decrease cerebral edema (Faye Glenn Abdellahs Concept of Twenty One Nursing Problems: To facilitate maintenance of elimination) A derivative of cytidine involved in the biosynthesis of lecithin. It increases blood flow and oxygen consumption in the brain. (Jean Watsons The Philosophy and Science of Caring: Nursing is concerned with promoting health, preventing illness, caring for the sick, and restoring health) Education can change human behaviour and thus, an effective way of

Dependent: Administer O2 inhalation 2LPM via nasal cannula prn for dyspnea as ordered Administer medications as indicated following the 10 rights of drug administration: > Mannitol 50cc q 8 (8am-4pm12mn) used as an osmotic

diuretic

Do health teaching to the patient and significant other on the effects of the medications administered as ordered. P Mannitol which increases blood and fluid supply to the extracellular space. To report any adverse effects such as headache, tachycardia, chest pain, nausea and vomiting. Citicoline which

promoting individual as well as his significant others health and well-being (Dorothea Orems Self-Care Theory: The act of assisting others in the provision and management of self-care to maintain/improve human function at home level of effectiveness)

increases oxygen consumption to the brain and observe for the adverse effects such as insomnia, excitement and shock.

CUES/EVIDENCES Subjective: Verbalized that she feels tired at times and even feels lazy to stand up to go to the toilet Feels dizzy when rising from bed Verbalizes that she feels difficulty in breathing and claims that the aid of O2 administration eases this problem Verbalized that hours PTA, she felt dizzy while she was sitting down and she felt sudden pain at the chest area

NURSING DIAGNOSIS Decreased cardiac output related to decreased blood pressure secondary to ischemic heart disease

OBJECTIVES Within our 2 days care, our client will improve tissue perfusion to the the peripheral areas of the body as evidenced by: Verbalized understanding of condition, therapy regimen, side effects of medication, and when to contact healthcare provider. Demonstrate behaviours/ lifestyle changes to improve circulation (eg. Relaxation techniques, exercise, dietary programs) Demonstrate increased perfusion as individually appropriate (eg. Peripheral pulses

INTERVENTIONS Independent: Monitor vital signs

RATIONALE

Provides comparison with current findings (Jean Watsons The Philosophy and Science of Caring: Nursing is concerned with promoting health, preventing illness, caring for the sick, and restoring health)

Inspect for pallor, cyanosis, mottling, cool/clammy skin. Note strength of peripheral pulse

Objective: Vital Signs: - T=37 C afebrile

Note for any sensory or motor changes, mental status

To note degree of impairment/organ involvement (Faye Glenn Abdellahs Concept of Twenty One Nursing Problems: To promote safety) To promote circulation/venous

- PR= 82 bpm weak - RR= 22 cpm regular with slight use of accessory muscle - BP=120/90 mmHg Capilliary refillgreater than 3 seconds Pale skin and mucous membranes of the mouth and palpebral conjunctiva Nail beds are also slightly pale X-RAY Result reveals calcified aortic knob; atheromatous aorta Hgb: 11 g/dl Troponin T (+) ECG 12- lead result reveals sinus rhythm with anterior lateral wall with myocardial ischemia

strong, vital signs within clients normal range, alert/oriented, balanced intake/output, free pain discomfort).

Elevate HOB (eg. 10) and maintain head/neck in midline or neural position

drainage (Florence Nightingales Environmental Theory: Focuses on changing and manipulating the environment in order to put the patient in the best possible condition for nature to act) To increase urine flow and to decrease cerebral edema (Faye Glenn Abdellahs Concept of Twenty One Nursing Problems: To facilitate maintenance of elimination) A derivative of cytidine involved in the biosynthesis of lecithin. It increases blood flow and oxygen consumption in the brain. (Jean Watsons The Philosophy and Science of Caring: Nursing is concerned with promoting health, preventing illness, caring for the sick, and

Collaborative: Mannitol 50cc q 8 (8am-4pm12mn) used as an osmotic diuretic

Citicholine 500mg 1tab TID used as an CNS Stimulant Citicholine 1gm IVTT q 8 used as an CNS Stimulant

restoring health) Education can change human behaviour and thus, an effective way of promoting individual as well as his significant others health and well-being (Dorothea Orems Self-Care Theory: The act of assisting others in the provision and management of self-care to maintain/improve human function at home level of effectiveness)

Do health teaching to the patient and significant other on the effects of the following medications: Mannitol which increases blood and fluid supply to the extracellular space. To report any adverse effects such as headache, tachycardia, chest pain, nausea and vomiting. Citicoline which increases oxygen consumption to the brain and observe for the adverse effects

such as insomnia, excitement and shock.

CUES/EVIDENCES Subjective: Verbalized that she feels tired at times and even feels lazy to stand up to go to the toilet Feels dizzy when rising from bed

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS Independent: Monitor vital signs

RATIONALE

Objective: Vital Signs: - T=37 C afebrile - PR= 82 bpm weak - RR= 22 cpm regular with slight use of accessory muscle - BP=120/90 mmHg Capilliary refillgreater than 3 seconds Pale skin and mucous membranes of the mouth and palpebral conjunctiva

Within our 2 days care, Pain r/t formation of our client will improve lactic acid due to tissue perfusion to the the decreased the peripheral areas of oxygen supply to the body as evidenced the myocardium by: (anaerobic metabolism) secondary to Verbalized ischemic heart understanding of disease condition, therapy regimen, side effects of medication, and when to contact healthcare provider. Demonstrate behaviours/ lifestyle changes to improve circulation (eg. Relaxation techniques, exercise, dietary programs) Demonstrate increased perfusion as individually appropriate (eg. Peripheral pulses

Provides comparison with current findings (Jean Watsons The Philosophy and Science of Caring: Nursing is concerned with promoting health, preventing illness, caring for the sick, and restoring health) To note degree of impairment/organ involvement (Faye Glenn Abdellahs Concept of Twenty One Nursing Problems: To promote safety) To promote circulation/venous drainage (Florence Nightingales Environmental Theory: Focuses on changing and manipulating the environment in order to

Note for any sensory or motor changes, mental status

Elevate HOB (eg. 10) and maintain head/neck in midline or neural position

Nail beds are also slightly pale X-RAY Result reveals calcified aortic knob; atheromatous aorta Hgb: 11 g/dl Troponin T (+) ECG 12- lead result reveals sinus rhythm with anterior lateral wall with myocardial ischemia

strong, vital signs within clients normal range, alert/oriented, balanced intake/output, free pain discomfort).

put the patient in the best possible condition for nature to act) Collaborative: Mannitol 50cc q 8 (8am-4pm12mn) used as an osmotic diuretic To increase urine flow and to decrease cerebral edema (Faye Glenn Abdellahs Concept of Twenty One Nursing Problems: To facilitate maintenance of elimination) A derivative of cytidine involved in the biosynthesis of lecithin. It increases blood flow and oxygen consumption in the brain. (Jean Watsons The Philosophy and Science of Caring: Nursing is concerned with promoting health, preventing illness, caring for the sick, and restoring health) Do health teaching to the Education can change human behaviour and thus, an effective way of promoting individual as well

Citicholine 500mg 1tab TID used as an CNS Stimulant Citicholine 1gm IVTT q 8 used as an CNS Stimulant

patient and significant other on the effects of the following medications: Mannitol which increases blood and fluid supply to the extracellular space. To report any adverse effects such as headache, tachycardia, chest pain, nausea and vomiting. Citicoline which increases oxygen consumption to the brain and observe for the adverse effects such as insomnia, excitement and shock.

as his significant others health and well-being (Dorothea Orems Self-Care Theory: The act of assisting others in the provision and management of self-care to maintain/improve human function at home level of effectiveness)