VIII. LIST OF PRIORITY PROBLEMS 1. Decreased cardiac output related to altered heart rate secondary to coronary atherosclerosis. 2.

Death anxiety related to cardiac event secondary to coronary atherosclerosis. 3. Sleep deprivation related to uncomfortable sleep environment

Cues/Data

Nursing Diagnosis

Rationale

Goals and Objectives

Nursing Intervention/s

Rationale

Evaluation

Subjective data: As verbalized by the client sobrang nagpalpitate ako kagabi.

Decreased cardiac output related to altered heart rate secondary to coronary atherosclerosis. As manifested by:

Objective: -dysrhythmias -tachycardia -bradycardia -dysrhythmias -tachycardia -bradycardia

Atheromas causes obstruction of blood flow that causes a decrease blood supply to cardiac muscle cells that deprives it of oxygen. Decrease oxygen to cardiac cells is called ischemia, ischemia causes angina pectoris. Angina pectoris causes myocardial damage that results to low cardiac output.

After 4 hours of nursing intervention the client will be able to display hemodynamic stability especially heart rate and blood pressure.

INDEPENDENT: -Keep client on bed or chair position of comfort. Semifowlers is preferred. -Decrease stimuli; provide quiet environment. -Monitor vital signs frequently.

.-Decreases oxygen consumption and risk of decompensation. -to promote adequate rest.

-to note response to interventions. -to minimize dehydration and dysrhythmias.

After 4 hours of nursing intervention the client was able to display hemodynamic stability especially heart rate and blood pressure as manifested by pulse rate of 68bpm and blood pressure is 120/80mmHg.

-provide fluids/electrolytes, as indicated.

DEPENDENT: -Administer cordarone 200mg 1tab BID. COLLABORATIVE: -Administer O 2Lpm via nasal cannula.

-For severe ventricular tachycardia

BP: 130/90mmHg

BP: 130/90mmHg

- to increase oxygen available for cardiac function.

Nursing Diagnosis Cues/Data Subjective: As verbalized by the client natatakot ako na anytime ay kunin ako ni Lord Death anxiety related to cardiac event secondary to coronary atherosclerosis

Rationale

Goals and Objectives After 2-4 hours of my nursing intervention the patient will express reduce anxiety.

Nursing Intervention/s

Rationale

Evaluation

Atheromas causes obstruction of blood flow that causes a decrease blood supply to cardiac muscle cells that deprives it of oxygen. Decrease oxygen to cardiac cells is called ischemia, ischemia causes angina pectoris. Angina pectoris causes myocardial damage that results to low cardiac output and heart failure where heart cannot support the bodys needs for blood. A decrease in blood supply from CAD may even cause the heart to abruptly stop beating (sudden cardiac death).

INDEPENDENT: -provide open and trusting relationship -use therapeutic communication skills of active-listening -do not deny or reassure client that everything will be all right. Be honest when answering questions/providing information -provide calm, peaceful setting and privacy as appropriate -music therapy -enhances trust and therapeutic relationship

After 2-4 hours of my nursing intervention the patient express reduce anxiety.

-promotes relaxation and ability to deal with situation -relax the patient

Nursing Diagnosis Cues/Data Subjective: As verbalized by the client hirap akong makatulog, dahil namamahay ako Objective: -restlesness, irritability -drowsy eyes -inability to concentrate Sleep deprivation related to uncomfortable sleep environment

Rationale

Goals and Objectives After 2-4 hours of my nursing intervention will identify individually appropriate interventions to promote sleep.

Nursing Intervention/s

Rationale

Evaluation

Prolonged periods of time without sleep caused by uncomfortable sleep environment can cause sleep deprivation.

INDEPENDENT: -encourage client to develop plan to restrict caffeine, alcohol, and other stimulating substances -suggest abstaining from daytime naps -investigate anxious feelings -these factors are known to disrupt sleep patterns

After 2-4 hours of my nursing intervention the client identified individually appropriate interventions to promote sleep.

-because they impair ability to sleep at night -to help determine basis and appropriate anxiety-reduction techniques. -to reduce stimulation so client can relax

-recommend quiet activities such as reading/listening to soothing music in the evening -instruct in relaxation techniques, music therapy, meditation DEPENDENT: -administer sedatives/other sleep medications, when indicated, noting clients response. COLLABORATIVE: -encourage family counselling

-to decrease tension, prepare for rest/sleep

-to help deal with concerns arising from parasomnias