Prioritization of Nursing problems

Nursing problem Ineffective Cardiopulmonary Tissue Perfusion

Cues Subjective: >Report of dyspnea even at rest >Palpitation >Chest pain at 9/10 pain scale Objective: >Use of accessory muscles when breathing* >Poor capillary refill (>5s)* >Pale skin >Pale mucous membrane >Hgb of 139 g/L >Hct of 0.42 >041510: 2-D Echo result shows Mild Tricuspid Regurgitation and impaired diastrolic relaxation of Left ventricle* >RR of 23cpm* PR of 104bpm* BP of 160/80mmHg

Justification It is prioritized hence as reference Maslows Hierarchy such it falls under physiological needs, such it must be met at least minimally to maintain life, as these needs are the most basic in the hierarchy as these are one of the most essential to life therefore it gained the highest priority ;Carol Taylor(2009) , thus the main problem is the disease condition which is Coronary Artery Disease which is the oxygenated blood distribution to the circulation is compromised , in relevance with that oxygen is the essential to all needs because cells needs oxygen for survival . Thus solving this nursing can alleviate or decrease the gravity of the other succeeding nursing problems hence those are the signs and symptoms of the disease condition which can chiefly addressed by intervening first at in this nursing problem

Acute pain

Subjective: -Pain scale of 9/10 for Chest pains Objective: . - Exhibits facial grimace upon palpation of the abdomen. -Shows signs of Irritability - Restlessness

This nursing problem is also falls under physiological needs on Ms lows Hierarchy of needs but in a way it is subsequent to the first nursing problem such the pain is result of omission to intervene with the prioritized problem . Pain hinder or limits physical activity such is physiological needs that should be achieved hence it is accomplished by intact and functioning system, in such pain must be relieved or eliminate to that so; Walker BR and Hunter JAA (2006).

NURSING CARE PLANS

PROBLEM #1 Ineffective (Cardiopulmonary) Tissue Perfusion Assessment Nursing Diagnosis Goals & Objectives Nursing Interventions Rationale Evaluation

Subjective: >Report of dyspnea even at rest >Palpitation >Chest pain at 9/10 pain scale Objective: >Use of accessory muscles when breathing* >Poor capillary refill (>5s)* >Pale skin >Pale mucous membrane >Hgb of 139 g/L >Hct of 0.42 >041510: 2-D Echo result shows Mild Tricuspid Regurgitation and impaired diastrolic relaxation of Left ventricle* >RR of 23cpm* PR of 104bpm* BP of 160/80mmHg

Ineffective Cardiopulmonary Tissue Perfusion secondary to impaired transport of oxygen (NANDA, 2009)

After 30 minutes of nursing intervention, these should manifest: >Relief of dyspnea without the use of accessory muscles > Chest Pain Scale from 6 to 1-4/10 >Skin normal in color >have a stable vital signs of BP=100/70140/80mmHg PR=60-100bpm RR=12-20cpm

>Encourage quiet, restful and peaceful environment >Inform client to avoid activities; like, straining at stool >Always monitor the blood pressure >Encourage use of relaxation techniques >Position patient in semi to high fowlers position >Encourage deep breathing exercises

*To conserve energy & body tissue O2 demand. *It increases cardiac workload

After 3 hrs of nursing intervention, the goal was partially met as manifested by

>Relief from dyspnea and breathing normally without th use of accessory muscles >Chest Pain scale of 4/10 >Skin pale in color *Hypertension >Vital Signs of 130/80mmHg can damage blood 93bpm and 18 cpm vessel & organ function *To decrease tension level *To promote optimal lung expansion & decreases cardiac workload

*To promote lung >Educate the expansion patient about * to enable for the his/her medication treatment to have regimen(e.g. taking of better outcome or vasodilators) result

PROBLEM #2 Acute pain Assessment Subjective: -Pain scale of 9/10 for abdominal pains Objective: . - Exhibits facial grimace upon palpation of the abdomen. -Shows signs of Irritability - Restlessness Chronic pain related to in adequate as manifested by the Pain scale of 9/10 for chest pains. Short Term: >Within 15-30 min of intermediate nursing intervention - Verbalize reduction/ relief of pain in the chest >Within 8 hours shift with average of nursing interventions, the patient will be able to: - Feel and palpate chest without facial grimace and moaning. - Recite and demonstrate some nonpharmacologic ways to lessen pain. Nursing Diagnosis Goals and Objectives Nursing interventions
Independent: -Provide comfort measures such as use of pillows under extremities and periodic wound cleaning on affected area. - Encourage and assist client to do deep breathing exercises. - Teach client and significant other about the nonpharmacologic ways to lessen the pain. - Instruct client to report any improvement/exacerbation in pain experience. - Encourage verbalization of feelings about the pain. - Physical Examination: Periodic auscultation of the abdomen for bowel sounds Inspection and Palpation for masses and tenderness. Dependent: - Administer medications, particularly analgesics, as prescribed. - Assist with laboratory/diagnostic studies as indicated.

Rationale
To promote relief and wellness.

Evaluation

After 8 hours shift of nursing intervention the patient verbalize Deep breathing reduction of exercises pain, goal is half contribute to relief met due to the of pain patient needs further To maximize examination opportunities for and medical self-control over pain intervention.
manifestations. Only the client can judge the level and distress of pain; pain management should be a team approach that includes the client. Necessary for management of underlying and possible complications.

(NANDA,2009)

PROBLEM #3 Impaired physical mobility Assessment Subjective: Objective: Limited ability and difficulty to perform gross motor skills General body weakness Slowed movement Nursing Diagnosis Impaired physical mobility related to disease condition ( Coronary Artery Disease) manifested by limitation of movement and work Goals & Objectives Intervention Rationale Independent: 1. To establish comparative baseline 2. To note any incongruenc e with the reports of abilities 3. Reduce risk of pressure ulcers 4. To help reduce fatigue and O2 demand 5. energy production Evaluation Long term goals met: Client is able to physical mobility as evidenced by resumption of activities, participation in his ADLs Short term goals met: The client is able to participate on the therapeutic regimen as evidenced by verbalization of understanding of the situation, therapy, and he is able to participate in the interventions rendered by the nurse

(NANDA, 2009)

Independent: Long term: 1. Determine After 4 days of nursing degree of intervention, client will immobility be able to physical 2. Observe mobility movement when Expected outcome: client is unaware 3. Support Demonstrate affected part resumption of with pillows activities 4. Give rest Participate in periods to ADLs activities 5. Encourage Maintain or adequate fluids muscle control and right diet as Short term: necessary to the After 8 hrs of nursing client intervention, client will be able to participate in therapeutic regimen Expected outcome: Verbalize understanding of the situation Verbalization of understanding the therapy Able to participate in the interventions rendered by the nurse