Care Plan Exercise

Cristi Day RN, MSN, FNP-C

Texas A&M University
Corpus Christi

Ineffective Tissue Perfusion: Cardiopulmonary

Definition:

Decrease in oxygen resulting

in failure to nourish tissues at capillary
level
Defining Characteristics (AEB): use of
accessory muscles, capillary refill longer
than 3 seconds, abnormal ABGs, chest
pain, sense of impending doom,
bronchospasm, dyspnea, dysrhythmias,
nasal flaring, chest retraction.

Ineffective Tissue Perfusion: Cardiopulmonary

Contd
Related

Factors (R/T): Hypovolemia,

interruption of arterial flow, hypervolemia,
exchange problems, interruption of venous
flow, mechanical reduction of venous and/or
arterial blood flow, hypoventilation, impaired
transport of oxygen across alveolar and/or
capillary membrane, mismatch of ventilation
with blood flow, decreased hemoglobin
concentration in blood, enzyme poisoning,
altered affinity of hemoglobin of oxygen

Ineffective Tissue Perfusion Nursing Diagnosis

Statement

Ineffective Tissue Perfusion:

cardiopulmonary R/T interruption of
aterial flow AEB altered RR, CP,
sense of impending doom, dyspnea

Ineffective Tissue Perfusion: Care Map

Ineffective Tissue Perfusion:

cardiopulmonary R/T
interruption of aterial flow
AEB altered RR, CP,
sense of impending
doom, dyspnea

CP
8/10

RR
24
SOB

Fees like
he going to
die

Ineffective Tissue Perfusion: Outcome Goals

1.

2.

Client will demonstrate adequate tissue

perfusion as evidenced by: skin warm &
dry, absence of dyspnea, absence of
chest pain, absence of feelings of
impending doom within 2 hours of
admission.
Client will verbalize knowledge of
treatment regimen including lifestyle
modifications, medical nutrition therapy,
and medication regimen actions and
possible side effects before discharge
from acute care.

Ineffective Tissue Perfusion: Care Map

Ineffective Tissue Perfusion:

cardiopulmonary R/T
interruption of aterial flow
AEB altered RR, CP,
sense of impending
doom, dyspnea

CP
8/10

RR
24

Fees like
he going to
die

SOB

1.

2.

Client will demonstrate

adequate tissue
perfusion as
evidenced by: skin
warm & dry, absence
of dyspnea, absence
of chest pain, &
absence of feelings of
impending doom within
2 hours of admission.
Client will verbalize
knowledge of
treatment regimen
including lifestyle
modifications, medical
nutrition therapy, and
medication regimen
actions and possible
side effects before
discharge from acute

Ineffective Tissue Perfusion: Interventions

Assess for signs of decreased tissue perfusion:
CP, clammy skin, dyspnea, feelings of impending
doom. RA: Indicative of inadequate blood supply
to myocardium (A&L p269)

Administer nitroglycerin SL and oxygen as

ordered. RA: This improves myocardial perfusion
(http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Const
ructor/index.cfm?plan=55

Teach client/family about medications, their

regimen, actions, and side effects. RA:
Appropriate instruction increases accuracy &
safety of medication administration. (A&L p 904)

Teach client/family importance and methods of

lifestyle modification and dietary modifications
for smoking cessation, hyperlipidemia control,
HTN control. RA: All these risk factors for
atherosclerosis can be modified. (A&L p 1237)

Anticipate need for possible embolectomy, heparinization, vasodilator

therapy, thrombolytic therapy, and fluid rescue. RA: These facilitate
perfusion when obstruction to blood flow exists or when perfusion
has dropped to such a danger level that ischemic damage would be
inevitable without treatment.
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?
plan=55

Ineffective Tissue Perfusion: Care Map

Ineffective Tissue Perfusion:
cardiopulmonary R/T
interruption of aterial flow AEB
altered RR, CP, sense of
impending doom, dyspnea

CP
8/10

RR
24

Fees like
hes going
to die

SOB
Assess for signs of decreased tissue perfusion: CP,
clammy skin, dyspnea, feelings of impending doom.
RA: Indicative of inadequate blood supply to
myocardium (A&L p269)

Administer nitroglycerin SL and oxygen as ordered.

RA: This improves myocardial perfusion
(http://www1.us.elsevierhealth.com)

Teach client/family about medications, their regimen,

actions, and side effects. RA: Appropriate
instruction increases accuracy & safety of medication
administration. (A&L p 904)

Teach client/family importance and methods of

lifestyle modification and dietary modifications for
smoking cessation, hyperlipidemia control, HTN
control. RA: All these risk factors for atheroslerosis
can be modified. (A&L p 1237)

Anticipate need for possible embolectomy,

heparinization, vasodilator therapy, thrombolytic
therapy, and fluid rescue. RA: These facilitate
perfusion when obstruction to blood flow exists
or when perfusion has dropped to such a
danger level that ischemic damage would be
inevitable without treatment.
http://www1.us.elsevierhealth.com

Client will demonstrate

adequate tissue
perfusion as
evidenced by: skin
warm & dry,
absence of
dyspnea, absence
of chest pain, &
absence of feelings
of impending doom
within 2 hours of
admission.
Client will verbalize knowledge
of treatment
regimen including
lifestyle
modifications,
medical nutrition
therapy, and
medication regimen
actions and
possible side
effects before
discharge from
acute care.

Ineffective Tissue Perfusion: Evaluation

1.

Client will demonstrate

adequate tissue perfusion
as evidenced by: skin
warm & dry, absence of
dyspnea, absence of chest
pain, & absence of feelings
of impending doom within
2 hours of admission.

2. Client will verbalize

knowledge of treatment
regimen including lifestyle
modifications, medical
nutrition therapy, and
medication regimen
actions and possible side
effects before discharge
from acute care.

1. Goal Partially Met. Client skin

warm and dry, no c/o dyspnea, chest

pain resolved, and feelings of
impending doom resolved within 8
hours of admission.
2. Goal Met. Client verbalizes
understanding of activity and dietary
changes needed to modify risks for CAD
and verbalizes understanding of
medications, their actions and side effects
prior to discharge to home.

Activity Intolerance
Definition:

Insufficient physiological or
psychological energy to endure or complete
required or desired daily activities.
Defining Characteristics (AEB): Verbal report
of fatigue or weakness, abnormal heart rate or
blood pressure response to activity, exertional
discomfort or dyspnea, electrocardiographic
changes reflecting arrhythmias or ischemia.

Activity Intolerance - Contd

Related

Factors (R/T): Bed rest or

immobility, generalized weakness,
sedentary lifestyle, imbalance between
oxygen supply and demand.

Activity Intolerance
Nursing Diagnosis Statement

Activity Intolerance R/T imbalance

between oxygen supply and
demand (CHF decreased Cardiac
Output) AEB fatigue, exertional
dyspnea.

Activity Intolerance : Care Map

Activity Intolerance R/T
imbalance between
oxygen supply and
demand (CHF decreased
Cardiac Output) AEB
fatigue, exertional
dyspnea.

c/o
fatigue

Exertional
dyspnea

Activity Intolerance : Outcome Goals

1.

2.

Client will demonstrate increased

activity intolerance (decrease
report of fatigue and decreased
exertional dyspnea by time of
discharge.
Client will verbalize an
understanding of the need to
gradually increase activity based on
testing, tolerance, and symptoms
by end of second day of admission.

Activity Intolerance : Interventions

Consider us of the 6-minute walk test to
determine physical ability. RA: The 6-minute walk
test was shown to be highly reproducible in
determining ability to ambulate in a client in Heart
Failure. (A&L p 152)

Provide emotional support and

encouragement to the client to gradually
increase activity. RA: Fear of breathlessness,
pain, or falling may decrase willingness to
increase activity. (A&L 151)

Allow for periods of rest before and after planned

exertion periods. RA: Limited exercise toleratnce
in heart failure is often the first and central clinical
feature, reflecting both decreased cardiac and
peripheral responses. (A&L 152)

Refer to cardiac rehab program for education,

evaluation, and support to increase activity and
rebuild life. RA: Exercise can help many client
with heart failure. A carefully monitored
exercise program can improve both exercise
capacity and quality of life in mild to moderate
heart failure clients (A&L 152)

Help client to set up an activity log to record

exercise and exercise tolerance. RA: Will help
client to understand his level of activity tolerance.
(A&L 155)

Activity Intolerance : Care Map

Activity Intolerance R/T
imbalance between
oxygen supply and
demand (CHF decreased
Cardiac Output) AEB
fatigue, exertional
dyspnea.

Consider us of the 6-minute

walk test to determine
physical ability. RA: The 6-minute
walk test was shown to be highly reproducible in
determining ability to ambulate in a client in Heart
Failure. (A&L p 152)

Help client to set up an

activity log to record exercise
and exercise tolerance. RA:
Will help client to understand his
level of activity tolerance. (A&L
155)

Provide emotional support

and encouragement to the
client to gradually increase
activity. RA: Fear of breathlessness, pain,
or falling may decrase willingness to increase
activity. (A&L 151)

c/o
fatigue

Exertional
dyspnea

1.

Allow for periods of rest

before and after planned
exertion periods. RA: Limited
exercise tolerance in heart failure is
often the first and central clinical
feature, reflecting both decreased
cardiac and peripheral responses.

(A&L 152)

Refer to cardiac rehab

program for education,
evaluation, and support to
increase activity and
rebuild life. RA: Exercise can
help many client with heart failure. A
carefully monitored exercise program
can improve both exercise capacity
and quality of life in mild to moderate
heart failure clients (A&L 152)

Client will
demonstrate
increased activity
intolerance
(decrease report of
fatigue and decreased
exertional dyspnea by
time of discharge.

2.

Client will verbalize

an understanding
of the need to
gradually increase
activity based on
testing, tolerance, and
symptoms by end of
second day of
admission.

Activity Intolerance : Evaluation

1. Goal met. Client demonstrated
increased activity intolerance. Able to
walk 150 ft without significant dyspnea
and without report of fatigue by
discharge home (4 days).

2. Goal met. Client was able to

identify activity tolerance and
symptoms of intolerance and
verbalized understanding of the
need to gradually increase his
activity by the 2nd day of
admission.

1.

2.

Client will demonstrate

increased activity
intolerance (decrease
report of fatigue and
decreased exertional
dyspnea by time of
discharge.
Client will verbalize an
understanding of the
need to gradually
increase activity based
on testing, tolerance, and
symptoms by end of
second day of admission.

CARE PLAN EVALUATION FORM

Problem List:
High Risk
Actual
Problems identified come from assessment data
All problems are noted that assessment data shows/ Priorities identified.

10

Nursing Diagnostic Statement:

Stated in nursing terms (NANDA format)
Related to is pathophysiologically based
Supported by Objective Data
Supported by Subjective Data

10

Goals and Outcomes:

Relate to Problem
States desired patient outcome criteria
Realistic time frame

Long and Short Term Goal,

Measurable

10

Carative Factors/Interventions:
Contain what, how much, where, when
Related to goals and outcomes
Could be completed by another nurse for the client

10

Rationale:
Based on Valid Theory; States what the nursing action modifies
within the body to accomplish the desired outcome
Refers to interventions, References (page and source)

10

Evaluation:
States how goal was met or not met
Recommended changes
Based on outcome criteria

10