Tuesday, December 22, 2009

Myocardial Infarction (MI)
Myocardial Infarction (MI)
Nursing care plans for Myocardial infarction (MI). Myocardial infarction (MI) or acute Myocardial infarction is an acute coronary syndrome, results from reduced blood flow through one or more coronary arteries, which causes myocardial ischemia and necrosis. Myocardial infarction (MI) results when myocardial tissue becomes necrotic because of absent or diminished blood supply. When myocardial tissue is deprived of oxygenated blood supply for a period of time, an area of myocardial necrosis develops, this necrosis is surrounded by injured and ischemic tissue. 
The infarction site depends on the vessels involved. For instance: 

  • Occlusion of the circumflex coronary artery causes a lateral Myocardial infarction (MI). 
  • Occlusion of the left anterior coronary artery causes an anterior Myocardial infarction (MI). 
  • Occlusion of the right coronary artery or one of its branches causes True posterior and inferior Myocardial infarction (MI) 
  • Right ventricular infarctions can also result from right coronary artery occlusion, can accompany inferior MI, and may cause right-sided heart failure. 
  • If a thrombus partially occludes a coronary vessel, distal microthrombi may cause necrosis in some myocytes, leading to a non-ST-segment elevation MI (NSTEMI). 
  • If a thrombus fully occludes the vessel for a prolonged time, an ST-segment elevation MI (STEMI) usually develops. 

Men are more susceptible to Myocardial infarction (MI) than premenopausal women, although incidence is rising among women who smoke and take a hormonal contraceptive. The incidence in postmenopausal women resembles that in men. 

Causes for Myocardial Infarction (MI) 
A Myocardial infarction (MI) results from occlusion of one of the coronary arteries. The occlusion can stem from atherosclerosis, thrombosis, platelet aggregation, or coronary artery stenosis or spasm. Predisposing risk factors include: 

  • Aging 
  • Diabetes Mellitus 
  • Elevated serum triglyceride, low-density lipoprotein, and cholesterol levels, and decreased serum high-density lipoprotein levels 
  • Excessive intake of saturated fats, carbohydrates, or salt 
  • Hypertension 
  • Obesity 
  • Positive family history of coronary artery disease 
  • Sedentary lifestyle 
  • Smoking 
  • Stress or a type a personality (aggressive, competitive attitude, addiction to work, chronic impatience). 
  • In addition, use of such drugs as amphetamines or cocaine can cause a Myocardial infarction (MI). 

Complications for Myocardial Infarction (MI) 
Cardiac complications of Acute Myocardial infarction (MI) 
Cardiogenic shock. 
Heart failure. 
Pulmonary edema 

Other complications for Myocardial Infarction (MI) include 

  • Rupture of the atrial or Ventricular septum, Ventricular wall, or valves; 
  • Ventricular aneurysms 
  • Cerebral or pulmonary emboli.
  •  Dressler’s syndrome can occur days to weeks after an Myocardial infarction (MI) and cause residual pain, malaise, and fever. 
  • Typically, elderly patients are more prone to complications and death. Psychological problems can also occur, either from the patient’s fear of another Myocardial infarction (MI) or from an organic brain disorder caused by tissue hypoxia. Occasionally, a patient may have a personality change. 

Nursing Assessment nursing care plans for Myocardial infarction (MI)
Symptomatology is very important in diagnosing Myocardial infarction (MI). Ask about chest, jaw, arm, and epigastric pain. Remember that not all people have the “typical” chest pain; evaluate the whole clinical picture because some people may experience no pain at all. Ask about shortness of breath, racing heart rate, diaphoresis, clammy skin, dizziness, nausea, and vomiting. Note that sudden death and full cardiac arrest may be the first indication of Myocardial infarction (MI). 
Patients with coronary artery disease may report increasing anginal frequency, severity, or duration (especially when not precipitated by exertion, a heavy meal, or cold and wind). The patient may also report a feeling of impending doom, fatigue, nausea, vomiting, and shortness of breath. Sudden death, however, may be the first and only indication of an Myocardial infarction (MI). 

Physical Examination

  • Inspection may reveal an extremely anxious and restless patient with dyspnea and diaphoresis. 
  • If right-sided heart failure is present, you may note jugular vein distention. 
  • Anterior Myocardial infarction (MI), patients exhibit sympathetic nervous system hyperactivity, such as tachycardia and hypertension. 
  • Patients with an inferior Myocardial infarction (MI) exhibit parasympathetic nervous system hyperactivity, such as bradycardia and hypotension. 
  • In patients who develop ventricular dysfunction, auscultation may disclose an S4, an S3, paradoxical splitting of S2, and decreased heart sounds. 
  • A systolic murmur of mitral insufficiency may be heard with papillary muscle dysfunction secondary to infarction. 
  • A pericardial friction rub may also be heard, especially in patients who have a transmural Myocardial infarction (MI) or have developed pericarditis. 
  • Fever is unusual at the onset of MI, but a low-grade fever may develop during the next few days. 

Diagnostic tests for Myocardial infarction (MI)
Persistent chest pain, ST-segment changes on ECG, and elevated levels of total creatine kinase (CK) and the CK-MB isoenzyme over a 72-hour period usually confirm Myocardial infarction (MI). Cardiac troponins are useful in differentiating MI from skeletal muscle injury, or when CK-MB measurements are low and a small MI has actually occurred. 
Diagnostic Highlights

  • Electrocardiogram 
  • Creatine kinase isoenzyme (MB-CK) 
  • Cardiac troponin I (cTnI) 
  • cardiac troponin T (cTnT) 

Elevated homocysteine and C-reactive protein levels have been found incidentally in patients with Myocardial infarction (MI) and may indicate a newer risk factor. The practical value of these tests remains unknown. Folic acid supplementation is used as treatment for elevated homocysteine levels

Nursing diagnosis Nursing Care Plans For Myocardial Infarction (MI).
Primary Nursing Diagnosis: Altered tissue perfusion (myocardial) related to narrowing of the coronary arteryies associated with atherosclerosis, spasm, or thrombosis
Common nursing diagnosis found on Myocardial infarction (MI).

  • Activity intolerance 
  • Acute pain 
  • Anxiety 
  • Decreased cardiac output 
  • Excess fluid volume 
  • Fatigue 
  • Imbalanced nutrition: Less than body requirements 
  • Ineffective coping 
  • Ineffective denial 
  • Ineffective sexuality patterns 
  • Ineffective tissue perfusion: Cardiopulmonary 

Nursing outcomes for Myocardial Infarction (MI), Patients will

  • Perform activities of daily living without excessive fatigue or exhaustion.
  • Express feelings of comfort and decreased pain. 
  • Verbalize strategies to reduce anxiety and stress. 
  • Maintain adequate cardiac output. 
  • Develop no complications of fluid volume excess. 
  • Verbalize the importance of balancing activities, as tolerated, with adequate rest periods. 
  • Achieve ideal weight. 
  • Develop adequate coping skills. 
  • The patient will recognize his acute condition and accept the lifestyle changes he needs to make. 
  • Express feelings about changes in sexual patterns. 
  • Maintain hemodynamic stability and develop no arrhythmias. 

Nursing interventions Nursing Care Plans for Myocardial Infarction (MI) 

  • Nursing Care for patients who have suffered a Myocardial Infarction (MI), Most most of them receive treatment in the coronary care unit (CCU), where they’re under constant observation for complications. 
  • On admission to the CCU, monitor and record the patient’s ECG readings, blood pressure, temperature, and heart and breath sounds. 
  • Assess pain and give an analgesic as ordered. 
  • Record the severity of pain, location, type, and duration of pain. 
  • Check the patient’s blood pressure before and after giving nitroglycerin, especially the first dose. 
  • Frequently monitor ECG rhythm strips to detect rate changes and arrhythmias. if any new arrhythmias are documented, if chest pain occurs, or at least every shift change or according to facility protocol. 
  • Obtain ECG readings and blood pressure and pulmonary artery catheter measurements, if applicable, to determine changes. During episodes of chest pain 
  • Watch for crackles, cough, tachypnea, and edema, which may indicate impending left-sided heart failure. 
  • Monitor daily weight, intake and output, respiratory rate, serum enzyme levels, ECG readings, and blood pressure. 
  • Organize patient care and activities to maximize periods of uninterrupted rest. 
  • Provide a clear liquid diet dietary until nausea subsides. A low-cholesterol, low-sodium diet, without caffeine-containing beverages, may be ordered. 
  • Provide a stool softener to prevent straining during defecation, which causes vagal stimulation and may slow heart rate. 
  • Allow the patient to use a bedside commode, and provide as much privacy as possible. 
  • Assist with ROM exercises. 
  • If the patient is immobilized by a severe Myocardial Infarction (MI), turn him often. 
  • Give Antiembolism stockings to prevent venostasis and thrombophlebitis. 
  • Provide emotional support, and help reduce stress and anxiety . 
  • If the patient has undergone PTCA, sheath care is necessary. Keep the sheath line open with a heparin drip. Observe the patient for generalized and site bleeding. Keep the leg with the sheath insertion site immobile. Maintain strict bed rest. Check peripheral pulses in the affected leg frequently. Provide an analgesic for back pain if needed. 
  • After thrombolytic therapy, administer continuous heparin as ordered. Monitor the partial thromboplastin time every 6 hours, and monitor the patient for evidence of bleeding. 

Patient Teaching and Home Healthcare Guide for Patients with Myocardial Infarction (MI) 
Explain procedures and answer questions for both the patient and family. Explain the CCU environment and routine. Remember that you may need to repeat explanations after the emergency situation has resolved. 

  • To promote compliance with the prescribed medication regimen and other treatment measures, thoroughly explain dosages and therapy. Inform the patient of the drug’s adverse reactions, and advise him to watch for and report signs and symptoms of toxicity (for example, anorexia, nausea, vomiting, mental depression, vertigo, blurred vision, and yellow vision, if the patient is receiving a cardiac glycoside). 
  • Explain the need to treat recurrent chest pain or Myocardial Infarction (MI) discomfort with sublingual nitroglycerin every 5 minutes for three doses. If the pain persists for 20 minutes, teach the patient to seek medical attention. If the patient has severe pain or becomes short of breath with chest pain, teach the patient to take nitroglycerin and seek medical attention right away 
  • Review dietary restrictions with the patient. If he must follow a low-sodium, low-fat, or low-cholesterol diet, provide a list of foods to avoid. Ask the dietitian to speak to the patient and family. 
  • Explore mechanisms to implement diet control, an exercise program, and smoking cessation if appropriate. 
  • Encourage the patient to participate in a cardiac rehabilitation exercise program. The physician and the exercise physiologist should determine the level of exercise and then discuss it with the patient and secure his agreement to a stepped-care program. 
  • Counsel the patient to resume sexual activity progressively. He may need to take nitroglycerin before sexual intercourse to prevent chest pain from the increased activity. 
  • Advise the patient about appropriate responses to new or recurrent symptoms. 
  • Advise the patient to report typical or atypical chest pain. Post Myocardial Infarction (MI) syndrome may develop, producing chest pain that must be differentiated from a recurrent MI, pulmonary infarction, and heart failure. 
  • Stress the need to stop smoking. If necessary, refer the patient to a support group. 
  • Be sure the patient understands all the medications, including the dosage, route, action, and adverse effects. 
  • Instruct the patient to keep the nitroglycerin bottle sealed and away from heat. 
  • The medication may lose patients potency.

Thursday, December 17, 2009

Nursing health Assessment part of nursing process: Assessment, Nursing diagnosis, Planning, Implementation, Evaluation. Nursing health Assessment is the process of collecting, validating, and clustering data. It is the first and most important step in the nursing process. The Nursing assessment phase sets the tone for the rest of the process, and the rest of the process flows from it. If your assessment is off the mark, then the rest of the process will be too. Nursing Assessment identifies your patient’s strengths and limitations and is performed not just once, but continuously throughout the nursing process. After performing your initial assessment, you establish your baseline, identify nursing diagnoses, and develop a plan. Then, as you implement your plan, you also assess your patient’s response. Finally, you assess the effectiveness of your plan of care for your patient 
The purpose of Nursing health assessment is to collect data of patient’s health status, to identify deviations from normal, to discover the patient’s strengths and coping resources, to point actual problems, and factors that place the patient at risk for health problems 

Data from nursing assessment can be classified as subjective and objective. 
Subjective data not measurable. They reflect what the patient is experiencing and include thoughts, beliefs, feelings, sensations, and perceptions. Subjective findings are referred to as symptoms. patients health history is an example of subjective data. 
Objective data are overt and measurable. Objective data are referred to as signs. Nursing physical examination and diagnostic studies are examples of objective data. Data sources are either primary or secondary. The patient is a primary data source. Secondary data sources come from anyone or anything aside from the patient, including family members, friends, other healthcare providers, and old medical records. Both primary and secondary data can also be subjective or objective. 

Assessment Process, Nursing health Assessment is an ongoing process. Every patient encounter provides you with an opportunity for assessment. 
Types of Assessment Nursing Assessments can be comprehensive or focused. A comprehensive assessment is usually the initial assessment. It is very thorough and includes a detailed health history and physical examination: 
comprehensive assessment examines the patient’s overall health status. 
focused assessment is problem oriented and may be the initial assessment or an ongoing assessment. focused assessment is frequently performed on an ongoing basis to monitor and evaluate the patient’s progress, interventions, and response to treatments. Even when a focused assessment is performed, it is important to look at the entire picture. A problem in one system will affect or be affected by every other system so scan your patient from head to toe and note any changes in other systems. Look for clues or pertinent data that will help you formulate your diagnosis.

Nursing Assessment and Medical Assessment 
Medical and nursing assessments should not contradict, each other in promoting the patient’s health and wellness. Often, data obtained through the nursing assessment contribute to the identification of medical problems. By working together in a collaborative relationship, nursing and medicine ensure the best possible care for patients 
Health Assessment is not unique to nursing. It is also an integral part of medical practice. The assessment process Could be same for nursing and medical practice, but the outcomes different. The goal of medical practice is to diagnose and treat disease. and The goal of nursing process is to diagnose and treat human responses to actual or potential health problems. Nursing assessment focuses on physiological and psychological responses and the psychosocial, cultural, developmental, and spiritual dimensions. It identifies patients’ responses to health problems as well as their strengths. Optimal level of wellness is the Nursing’s aim.

Methods of Collecting Data 

  • Interviews 
  • Observation 
  • Physical Assessment

Wednesday, December 16, 2009

Nursing Care Plans for Congestive Heart Failure (CHF). Heart failure (also called congestive heart failure or CHF). Most heart failure is the consequence of systolic dysfunction, the progressive deterioration of myocardial contractile function; this is most commonly due to ischemic heart disease or hypertension. Heart failure may be caused by valve failure (e.g., endocarditis) or can also occur in normal hearts suddenly burdened with an abnormal load (e.g. fluid or pressure overload). The heart is unable to pump blood at a rate that meets the requirements of the metabolizing tissues, or can only do so only with filling pressures that are higher than normal. 
Heart failure HF, often referred to as congestive heart failure (CHF), is the inability of the heart to pump sufficient blood to meet the needs of the tissues for oxygen and nutrients. 
Heart failure is a clinical syndrome that results from the progressive process of remodeling, in which mechanical and biochemical forces alter the size, shape, and function of the ventricle’s ability to pump enough oxygenated blood to meet the metabolic demands of the body. 

Causes For Congestive Heart Failure (CHF)

  1. Caused by disorders of heart muscle resulting in decreased contractile properties of the heart; CHD leading to MI; hypertension; valvular heart disease; congenital heart disease; cardiomyopathies; dysrhythmias. 
  2. Other causes include: 
  • Pulmonary embolism; chronic lung disease. 
  • Hemorrhage and anemia. 
  • Anesthesia and surgery. 
  • Transfusions or infusions. 
  • Increased body demands (fever, infection, pregnancy, arteriovenous fistula). 
  • Drug-induced. 
  • Physical and emotional stress. 
  • Excessive sodium intake. 

Pathophysiology for Congestive Heart Failure (CHF)
Congestive Heart Failure
Congestive Heart Failure
Systolic function of the heart and resulting cardiac output is governed by four major determinants: the contractile state of the myocardium, the preload of the ventricle (the end-diastolic volume and the resultant fiber length of the ventricles prior to onset of the contraction), the afterload applied to the ventricles (the impedance to LV ejection), and the heart rate. 
Cardiac function may be inadequate as a result of alterations in any of these determinants. In most instances, the primary derangement is depression of myocardial contractility caused either by loss of functional muscle (due to myocardial infarction, etc) or by processes diffusely affecting the myocardium. However, the heart may fail as a pump because preload is excessively elevated, such as in valvular regurgitation, or when afterload is excessive, such as in aortic stenosis or in severe hypertension. Pump function may also be inadequate when the heart rate is too slow or too rapid. Whereas the normal heart can tolerate wide variations in preload, afterload, and heart rate, the diseased heart often has limited reserve for such alterations. Finally, cardiac pump function may be supranormal but nonetheless inadequate when metabolic demands or requirements for blood flow are excessive. Causes of high output include thyrotoxicosis, severe anemia, arteriovenous shunting (including dialysis fistulas), Paget disease of bone, and thiamine deficiency (beriberi). 
Cardiac compensatory mechanisms (increases in heart rate, vasoconstriction, heart enlargement) occur to assist the struggling heart. 
  • These mechanisms are able to compensate for the heart’s inability to pump effectively and maintain sufficient blood flow to organs and tissue at rest. 
  • Physiologic stressors that increase the workload of the heart (exercise, infection) may cause these mechanisms to fail and precipitate the clinical syndrome associated with a failing heart (elevated ventricular/atrial pressures, sodium and water retention, decreased CO, circulatory and pulmonary congestion). 
  • The compensatory mechanisms may hasten the onset of failure because they increase afterload and cardiac work. 
Two types of dysfunction may exist with heart failure
Systolic failure poor contractility of the myocardium resulting in decreased CO and a resulting increase in the systemic vascular resistance. The increased SVR causes an increase in the afterload (the force the left ventricle must overcome in order to eject the volume of blood).
Diastolic failure stiff myocardium, which impairs the ability of the left ventricle to fill up with blood. This causes an increase in pressure in the left atrium and pulmonary vasculature causing the pulmonary signs of heart failure.
Heart failure may be right sided or left sided (or both) :

Left-Sided Heart Failure (Forward Failure)
Congestion occurs mainly in the lungs from blood backing up into pulmonary veins and capillaries.
  • Shortness of breath, dyspnea on exertion, paroxysmal nocturnal dyspnea (due to reabsorption of dependent edema that has developed during day), orthopnea, pulmonary edema 
  • Cough may be dry, unproductive; usually occurs at night 
  • Fatigability from low CO, nocturia, insomnia, dyspnea, catabolic effect of chronic failure. 
  • Insomnia, restlessness. 
  • Tachycardia S3 ventricular gallop. 
Right-Sided Heart Failure (Backward Failure)
Signs and symptoms of elevated pressures and congestion in systemic veins and capillaries:
  • Edema of ankles; unexplained weight gain (pitting edema is obvious only after retention of at least 10 lb [4.5 kg] of fluid) 
  • Liver congestion may produce upper abdominal pain 
  • Distended jugular veins 
  • Abnormal fluid in body cavities (pleural space, abdominal cavity) 
  • Anorexia and nausea from hepatic and visceral engorgement 
  • Nocturia diuresis occurs at night with rest and improved CO 
  • Weakness
Functional Classification of Heart Disease 
In the management of patients with heart disease, it is important to quantify and monitor the severity of symptoms. A commonly used classification system is that of the New York Heart Association (NYHA), shown below. 

  • Class I: No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, dyspnea, or anginal pain.
  • Class II: Slight limitation of physical activity. Ordinary physical activity results in symptoms. 
  • Class III: Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms. 
  • Class IV: Unable to engage in any physical activity without discomfort. Symptoms may be present even at rest. 
Recent recommendations propose that patients with heart failure be classified into four stages: 

  • Stage A: Those at high risk for congestive heart failure (CHF) but no structural heart disease (ie, hypertension, coronary artery disease [CAD]) and no symptoms. Patients at high risk for developing heart failure because of the presence of conditions that are strongly associated with the development of heart failure. Such patients have no identified structural or functional abnormalities of the pericardium, myocardium, or cardiac valves and have never shown symptoms or signs of heart failure. 
  • Stage B: Those with structural heart disease associated with CHF and no symptoms. Patients who have developed structural heart disease that is strongly associated with the development of heart failure but who have never shown symptoms or signs of heart failure. 
  • Stage C: Those with structural heart disease who have current or prior symptoms. Patients who have current or prior symptoms of heart failure associated with underlying structural heart disease. 
  • Stage D: Those with refractory CHF requiring some device or special intervention. Patients with advanced structural heart disease and marked symptoms of heart failure at rest despite maximal medical therapy and who require specialized interventions. 

Management For Congestive Heart Failure (CHF) 

  • Stage A focuses on eliminating risk factors by initiating therapeutic lifestyle changes and controlling chronic diseases, such as hypertension and diabetes. Beta-adrenergic blockers, ACE inhibitors, and diuretics are useful in treating this stage. 
  • Stage B treatment similar to Stage A, with emphasis on use of ACE Inhibitors and beta adrenergic blockers. 
  • Stage C same as A and B, but with closer surveillance and follow up. Digoxin is typically added to the treatment plan in this stage. Drug classes to be avoided due to worsening of heart failure symptoms include antiarrhythmic agents, calcium channel blockers, NSAIDs. 
  • Stage D may need mechanical circulatory support, continuous inotropic therapy, cardiac transplantation, or palliative care. Treatment aimed at decreasing excess body fluid. May not tolerate other classes of drugs used in previous stages. 


  • Diuretics 
  • Positive inotropic agents increase the heart’s ability to pump more effectively by improving the contractile force of the muscle. 
  • Vasodilator therapy decreases the workload of the heart by dilating peripheral vessels. 
  • Angiotensin-converting enzyme (ACE) inhibitors inhibit the adverse effects of angiotensin II (potent vasoconstriction/sodium retention). 
  • Aldosterone antagonists decrease sodium retention, sympathetic nervous system activation and cardiac remodeling. 
  • Human B-type natriuretic peptide (Nesiritide) used in patients with decompensated heart failure. 
  • Beta-adrenergic blockers decrease myocardial workload and protect against fatal dysrhythmias by blocking norepi-nephrine effects of the sympathetic nervous system. 
  • Angiotensin II-receptor blockers (ARBs) similar to ACE inhibitors. Used in patients who cannot tolerate ACE inhibitors due to cough or angioedema. 

Diet Therapy 
Restricted sodium 
Restricted fluids 


  • Intractable or refractory heart failure becomes progressively refractory to therapy (does not yield to treatment). 
  • Cardiac dysrhythmias. 
  • Myocardial failure and cardiac arrest. 
  • Digoxin toxicity from decreased renal function and potassium depletion. 
  • Pulmonary infarction, pneumonia, and emboli. 

Nursing Care Plans for Congestive Heart Failure (CHF). 

Nursing Assessment Nursing Care Plans for Congestive Heart Failure (CHF). 
Patients Health History Obtain history of symptoms, limits of activity, response to rest, and history of response to drug therapy. The nurse explores sleep disturbances, particularly sleep suddenly interrupted by shortness of breath. The nurse also asks about the number of pillows needed for sleep (an indication of orthopnea), activities of daily living, and the activities that cause shortness of breath. The nurse helps patients to identify things that they have lost because of the diagnosis, their emotional response to that loss, and successful coping skills that they have used previously. Family and significant others are often included in these discussions. 

Physical Examination Nursing Care Plans for Congestive Heart Failure (CHF). 
Assess peripheral arterial pulses; note quality, character; assess heart rhythm and rate and BP; assess edema. Inspect and palpate precordium for lateral displacement of PMI. Obtain hemodynamic measurements as indicated and note change from baseline. Assess weight and ask about baseline weight. Note results of serum electrolyte levels and other laboratory tests. Identify sleep patterns and sleep aids commonly used by patient. 

Nursing Diagnosis Nursing Care Plans for Congestive Heart Failure (CHF). 

  • Decreased Cardiac Output related to impaired contractility and increased preload and afterload 
  • Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures 
  • Excess Fluid Volume related to sodium and water retention 
  • Activity Intolerance related to oxygen supply and demand imbalance 

Nursing Interventions and Evaluation Nursing Care Plans for Congestive Heart Failure (CHF).
Nursing Diagnose
Decreased Cardiac Output related to impaired contractility and increased preload and afterload

Maintaining Adequate Cardiac Output
·   Place patient at physical and emotional rest to reduce work of heart.
    • Provide rest in semi-recumbent position or in armchair in air-conditioned environment reduces work of heart, increases heart reserve, reduces BP, decreases work of respiratory muscles and oxygen utilization, improves efficiency of heart contraction; recumbency promotes diuresis by improving renal perfusion.
    • Provide bedside commode to reduce work of getting to bathroom and for defecation.
    • Provide for psychological rest emotional stress produces vasoconstriction, elevates arterial pressure, and speeds the heart.
  • Evaluate frequently for progression of left-sided heart failure. Take frequent BP readings.
  • Auscultate heart sounds frequently and monitor cardiac rhythm.
  • Observe for signs and symptoms of reduced peripheral tissue perfusion: cool temperature of skin, facial pallor, poor capillary refill of nail beds.
  • Administer pharmacotherapy as directed.
  • Monitor clinical response of patient with respect to relief of symptoms (lessening dyspnea and orthopnea, decrease in crackles, relief of peripheral edema).

Normal BP and heart rate

Impaired Gas Exchange related to alveolar edema due to elevated ventricular pressures

Improving Oxygenation
  • Raise head of bed 8 to 10 inches (20 to 30 cm) reduces venous return to heart and lungs; alleviates pulmonary congestion.
    • Support lower arms with pillows to eliminate pull of their weight on shoulder muscles.
    • Sit orthopneic patient on side of bed with feet supported by a chair, head and arms resting on an over-the-bed table, and lumbosacral area supported with pillows.
  • Auscultate lung fields at least every 4 hours for crackles and wheezes in dependent lung fields (fluid accumulates in areas affected by gravity).
  • Observe for increased rate of respirations (could be indicative of falling arterial pH).
  • Observe for Cheyne-Stokes respirations (may occur in elderly patients because of a decrease in cerebral perfusion stimulating a neurogenic response).
  • Position the patient every 2 hours (or encourage the patient to change position frequently) to help prevent atelectasis and pneumonia.
  • Encourage deep-breathing exercises every 1 to 2 hours to avoid atelectasis.
  • Offer small, frequent feedings to avoid excessive gastric filling and abdominal distention with subsequent elevation of diaphragm that causes decrease in lung capacity.
  • Administer oxygen as directed.

Respiratory rate 16 to 20, ABG levels within normal limits, no signs of crackles or wheezes in lung fields

Excess Fluid Volume related to sodium and water retention

Restoring Fluid Balance
  • Administer prescribed diuretic as ordered.
  • Give diuretic early in the morning nighttime diuresis disturbs sleep.
  • Keep input and output record patient may lose large volume of fluid after a single dose of diuretic.
  • Weigh patient daily to determine if edema is being controlled: weight loss should not exceed 1 to 2 lb (0.5 to 1 kg)/day.
  • Assess for signs of hypovolemia caused by diuretic therapy thirst, decreased urine output, orthostatic hypotension, weak, thready pulse, increased serum osmolality, and increased urine specific gravity.
  • Be alert for signs of hypokalemia, which may cause weakening of cardiac contractions and may precipitate digoxin toxicity in the form of dysrhythmias, anorexia, nausea, vomiting, abdominal distention, paralytic ileus, paresthesias, muscle weakness and cramps, confusion.
  • Give potassium supplements as prescribed.
  • Be aware of disorders that may be worsened by diuretic therapy including hyperuricemia, gout, volume depletion, hyponatremia, magnesium depletion, hyperglycemia, and diabetes mellitus. Also, note that some patients allergic to sulfa drugs may also be allergic to thiazide diuretics.
  • Watch for signs of bladder distention in elderly male patients with prostatic hyperplasia.
  • Administer I.V. fluids carefully through an intermittent access device to prevent fluid overload.
  • Monitor for pitting edema of lower extremities and sacral area. Use convoluted foam mattress and sheepskin to prevent pressure ulcers (poor blood flow and edema increase susceptibility).
  • Observe for the complications of bed rest pressure ulcers (especially in edematous patients), phlebothrombosis, pulmonary embolism.
  • Be alert to complaints of right upper quadrant abdominal pain, poor appetite, nausea, and abdominal distention (may indicate hepatic and visceral engorgement).
  • Monitor patient's diet. Diet may be limited in sodium to prevent, control, or eliminate edema; may also be limited in calories.
  • Caution patients to avoid added salt in food and foods with high sodium content.

Weight decrease of 2.2 lb (1 kg) daily, no pitting edema of lower extremities and sacral area

Activity Intolerance related to oxygen supply and demand imbalance
Improving Activity Tolerance
  • Increase patient's activities gradually. Alter or modify patient's activities to keep within the limits of his cardiac reserve.
    • Assist patient with self-care activities early in the day (fatigue sets in as day progresses).
    • Be alert to complaints of chest pain or skeletal pain during or after activities.
  • Observe the pulse, symptoms, and behavioral response to increased activity.
    • Monitor patient's heart rate during self-care activities.
    • Allow heart rate to decrease to preactivity level before initiating a new activity.
  • Relieve nighttime anxiety and provide for rest and sleep patients with heart failure have a tendency to be restless at night because of cerebral hypoxia with superimposed nitrogen retention. Give appropriate sedation to relieve insomnia and restlessness.

Heart rate within normal limits, rests between activities

Wednesday, December 9, 2009

Nursing Assessment is the process of collecting, validating, and clustering data. It is the first and most important step in the nursing process. The assessment phase sets the tone for the rest of the process, and the rest of the process flows from it. If your assessment is off the mark, then the rest of the process will be too. Assessment identifies your patient’s strengths and limitations and is performed not just once, but continuously throughout the nursing process. After performing your initial assessment, you establish your baseline, identify nursing diagnosis, and develop a Nursing Care Plans. Then, as you implement your plan, you also assess your patient’s response. Finally, you assess the effectiveness of your plan of care for your patient. 
The purpose of assessment is to collect data of patient’s health status, to identify deviations from normal, to discover the patient’s strengths and coping resources, to point actual problems, and factors that place the patient at risk for health problems
Bipolar disorder
Bipolar disorder
Nursing care Plans for Bipolar disorder. Bipolar disorder these disorders are characterized by mood swings from profound depression to extreme euphoria (manic), with intervening periods of normalcy. Some patients suffer from acute attacks of mania only. 

Bipolar I Disorder 
Bipolar I disorder is the diagnosis given to an individual who is experiencing, or has experienced, a full syndrome of manic or mixed symptoms. The client may also have experienced episodes of depression. 

Bipolar II Disorder
Bipolar II disorder is characterized by recurrent bouts of major depression with the episodic occurrence of hypomania. This individual has never experienced a full syndrome of manic or mixed symptoms. 

Cyclothymia Disorder 
A variant of bipolar disorder, numerous episodes of hypomania and depressive symptoms are too mild to meet the criteria for major depression or bipolar illness. The essential feature is a chronic mood disturbance of at least 2 years’ duration, involving numerous periods of depression and hypomania 

Treatment for Bipolar disorder 
Lithium proves highly effective in relieving and preventing manic episodes. But has a narrow therapeutic range, so treatment must be initiated cautiously and the dosage adjusted slowly. The drug curbs the accelerated thought processes and hyperactive behavior without the sedating effect of antipsychotic drugs. In addition, it may prevent the recurrence of depressive episodes; however, it’s ineffective in treating acute depression. 
Valproic acid is an alternative to lithium. Antidepressants occasionally are used to treat depressive symptoms. However, these drugs may trigger a manic episode. 

Nursing diagnosis nursing care Plans for Bipolar disorder 
Common nursing diagnosis found in Nursing care Plans for Bipolar disorder: 
  • Risk for suicide 
  • Chronic low self-esteem 
  • Disturbed personal identity 
  • Disturbed thought processes 
  • Impaired social interaction 
  • Ineffective coping 
  • Ineffective health maintenance 
  • Ineffective role performance 

Nursing interventions nursing care Plans for Bipolar disorder 
Nursing interventions for Bipolar disorder With nursing diagnosis Risk for suicide 
Nursing Diagnosis
Risk for suicide
·     Client will seek out staff when feeling urge to harm self
·     Client will make short-term verbal (or written) contract with nurse not to harm self.
·     Client will not harm self.
·     Client verbalizes no thoughts of suicide.
·     Client commits no acts of self-harm.
·     Client is able to verbalize names of resources outside the hospital from whom he or she may request help if feeling suicidal.
·     Ask client directly: about how when where you will harming yourself? If so, what do you plan to do? Do you have the means to carry out this plan?”
·     Create a safe environment for the client.
·     Remove harmful objects e.g (glass, belts, rope, bobby pins).
·     Supervise his medications.
·     Institute suicide precautions as dictated by facility policy.
·     Formulate a short-term verbal or written contract with the client that he or she will not harm self.
·     Secure promise from client that he or she will seek out a staff member or support person if any thoughts of suicide.
·     Maintain close observation of client. Place in room close to nurse’s station; do not assign to private room
·     Make rounds at, irregular intervals.
·     Encourage verbalizations of honest feelings.  Through exploration and discussion, help client to identify symbols of hope in his or her life.
·     Encourage client to express angry feelings within appropriate limits. Provide safe method of hostility release. Help client to identify true source of anger and to work on adaptive coping skills for use outside the treatment setting.
·     Identify community resources that client may use as support system and from whom he or she may request help if feeling suicidal.
·     Orient client to reality.
·     Spend time with client.

Client will not harm self.

Patient teaching nursing care Plans for Bipolar disorder 

  • Drugs may cause adverse reactions If the patient is taking lithium, teach him and his family to discontinue the drug and notify the physician if signs of toxicity occur, including diarrhea, abdominal cramps, vomiting, unsteadiness, drowsiness, muscle weakness, polyuria, and tremors. 
  • Lithium may impair mental and physical function; caution against driving or operating dangerous equipment while taking the drug. 
  • Teach the patient the importance of continuing his medication regimen even when he doesn’t feel a need for it. 
  • Advise the patient to discontinue medications only with the physician’s approval because abrupt withdrawal could cause severe symptoms.

Monday, December 7, 2009

Kidney Anatomy
Nursing Care Plans for Acute Renal Failure; Acute renal failure is a syndrome of varying causation that results in a sudden decline in renal function. It is frequently associated with an increase in BUN and creatinine, oliguria (less than 500 ml urine/24 hours), hyperkalemia, and sodium retention (Williams & Wilkins, 2006). 
Acute renal failure (ARF) is a sudden and almost complete loss of kidney function (decreased Glomerular filtration rate GFR) over a period of hours to days. Acute Renal Failure ARF manifests with oliguria, anuria, or normal urine volume. Oliguria (less than 400 ml/day of urine) is the most common clinical situation seen in Acute Renal Failure ARF; anuria (less than 50 ml/day of urine) and normal urine output are not as common. Regardless of the volume of urine excreted, the patient with ARF experiences rising serum creatinine and BUN levels and retention of other metabolic waste products (azotemia) normally excreted by the kidneys (Brunner and Suddarth,2003 ). 
Acute renal failure (ARF) is the abrupt deterioration of renal function that results in the accumulation of fluids, electrolytes, and metabolic waste products. The sudden interruption of renal function resulting from obstruction, reduced circulation, or renal parenchymal disease. This condition is classified as prerenal, intrarenal, or postrenal and normally passes through three distinct phases: oliguric, diuretic, and recovery. It’s usually reversible with medical treatment. If not treated, it may progress to end-stage renal disease, uremia, and death. 

Causes for Acute Renal Failure 
Prerenal Failure 
Prerenal conditions occur as a result of impaired blood flow that leads to hypoperfusion of the kidney and a drop in the Glomerular filtration rate GFR. 

  • Volume depletion resulting from: Hemorrhage Renal losses (diuretics, osmotic diuresis) Gastrointestinal losses (vomiting, diarrhea, nasogastric suction) 
  • Impaired cardiac efficiency resulting from: Myocardial infarction Heart failure Dysrhythmias Cardiogenic shock 
  • Vasodilation resulting from: Sepsis Anaphylaxis Antihypertensive medications or other medications that cause Vasodilation 

Intrarenal Failure 
Intrarenal causes of ARF are the result of actual parenchymal damage to the glomeruli or kidney tubules. Intrarenal causes result from injury to renal tissue and are usually associated with intrarenal ischemia, toxins, immunologic processes, systemic and vascular disorders. 

  • Prolonged renal ischemia resulting from: Pigment nephropathy (associated with the breakdown of blood cells containing pigments that in turn occlude kidney structures) Myoglobinuria (trauma, crush injuries, burns) Hemoglobinuria (transfusion reaction, hemolytic anemia) 
  • Nephrotoxic agents such as: Aminoglycoside antibiotics (gentamicin, tobramycin) Radiopaque contrast agents Heavy metals (lead, mercury) Solvents and chemicals (ethylene glycol, carbon tetrachloride, arsenic) Nonsteroidal anti-inflammatory drugs (NSAIDs) Angiotensin-converting enzyme inhibitors (ACE inhibitors) 
  • Infectious processes such as: Acute pyelonephritis Acute glomerulonephritis 

Postrenal Failure 
Postrenal causes of ARF are usually the result of an obstruction somewhere distal to the kidney. Pressure raises in the kidney tubules eventually, the Glomerular filtration rate GFR decreases. 
Urinary tract obstruction, including: Calculi (stones), Tumors, Benign prostatic hyperplasia, Strictures, Blood clots.

Pathophysiology of Acute Renal Failure 
There are four clinical phases of Acute Renal Failure ARF: 
Pathophysiology of Acute Renal Failure
Pathophysiology of Acute Renal Failure

  1. The initiation period begins with the initial insult and ends when oliguria develops. 
  2. The oliguria period is accompanied by a rise in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium]). The minimum amount of urine needed to rid the body of normal metabolic waste products is 400 ml. In this phase uremic symptoms first appear life-threatening conditions such as hyperkalemia develop. 
  3. The diuresis period, the third phase, the patient experiences gradually increasing urine output which signals that Glomerular filtration has started to recover. Laboratory values stop rising and eventually decrease. Although the volume of urinary output may reach normal or elevated levels, renal function may still be markedly abnormal. Because uremic symptoms may still be present, the need for expert medical and nursing management continues. 
  4. The recovery period signals the improvement of renal function and may take 3 to 12 months. Laboratory values return to the patient’s normal level. Although a permanent 1% to reduction in the GFR is common, it is not clinically significant. 

Clinical Manifestations 

  • Prerenal decreased tissue turgor, dryness of mucous membranes, weight loss, hypotension, oliguria or anuria, flat neck veins, tachycardia 
  • Postrenal obstruction to urine flow, obstructive symptoms of BPH, possible nephrolithiasis 
  • Intrarenal presentation based on cause; edema usually present 
  • Changes in urine volume and serum concentrations of BUN, creatinine, potassium, and so forth, as described above 

Assessment and Diagnostic Findings Nursing Care Plans for Acute Renal Failure: 

  • Changes in urine 
  • Change in kidney contour 
  • Increased bun and creatinine levels (azotemia) 
  • Hyperkalemia 
  • Metabolic acidosis 
  • Calcium and phosphorus abnormalities 
  • Anemia 


  • Infection 
  • Arrhythmias due to hyperkalemia 
  • Electrolyte (sodium, potassium, calcium, phosphorus) abnormalities 
  • GI bleeding due to stress ulcers 
  • Multiple organ systems failure 

Nursing Process 
Nursing Assessment Nursing Care Plans for Acute Renal Failure 

  • Determine if there is a history of cardiac disease, malignancy, sepsis, or intercurrent illness. 
  • Determine if patient has been exposed to potentially nephrotoxic drugs (antibiotics, NSAIDs, contrast agents, solvents). 
  • Conduct an ongoing physical examination for tissue turgor, pallor, alteration in mucous membranes, blood pressure, heart rate changes, pulmonary edema, and peripheral edema. 
  • Monitor intake and output 

Nursing Diagnosis Nursing Care Plans for Acute Renal Failure 
Common nursing diagnosis found in Nursing Care Plans for Acute renal failure: 

  • Excess Fluid Volume related to decreased glomerular filtration rate and sodium retention 
  • Risk for Infection related to alterations in the immune system and host defenses 
  • Imbalanced Nutrition: Less Than Body Requirements related to catabolic state, anorexia, and malnutrition associated with acute renal failure 
  • Risk for Injury related to GI bleeding 
  • Disturbed Thought Processes related to the effects of uremic toxins on the central nervous system (CNS)
Nursing Intervention, Evaluation, Out Come, Patient Teaching and Home Healthcare Guidelines Nursing Care Plans For Acute Renal Failure. Nursing interventions with nursing diagnosis; Excess Fluid Volume, Risk for Infection, Imbalanced Nutrition: Less Than Body Requirements, Risk for Injury, Disturbed Thought Processes.

Nursing Diagnose
Excess fluid volume related to decreased Glomerular filtration rate and sodium retention

Achieving fluid and electrolyte balance
  • Monitor for signs and symptoms of hypovolemia or hypervolemia because regulating capacity of kidneys is inadequate.
  • Monitor urinary output and urine specific gravity; measure and record intake and output including urine, gastric suction, stools, wound drainage, perspiration (estimate).
  • Monitor serum and urine electrolyte concentrations.
  • Adjust fluid intake to avoid volume overload and dehydration
  • Measure blood pressure regularly with patient in supine, sitting, and standing positions.
  • Auscultate lung fields for rales.
  • Inspect neck veins for engorgement and extremities, abdomen, sacrum, and eyelids for edema.
  • Evaluate for signs and symptoms of hyperkalemia, and monitor serum potassium levels.
  • Administer sodium bicarbonate or glucose and insulin to shift potassium into the cells.
  • Administer cation exchange resin (sodium polystyrene sulfonate [Kayexalate]) orally or rectally to provide more prolonged correction of elevated potassium.
  • Watch for cardiac arrhythmia and heart failure from hyperkalemia, electrolyte imbalance, or fluid overload. Have resuscitation equipment on hand in case of cardiac arrest.
  • Instruct patient about the importance of following prescribed diet, avoiding foods high in potassium.
  • Prepare for dialysis when rapid lowering of potassium is needed.
  • Administer blood transfusions during dialysis to prevent hyperkalemia from stored blood.
·         Monitor acid base balance.
Blood pressure stable, no edema or shortness of breath
Risk for infection related to alterations in the immune system and host defenses

Preventing infection
  • Monitor for all signs of infection. Be aware that renal failure patients do not always demonstrate fever and leukocytosis.
  • Remove bladder catheter as soon as possible; monitor for UTI.
  • Use intensive pulmonary hygiene high incidence of lung edema and infection.
  • Carry out meticulous wound care.
  • If antibiotics are administered, care must be taken to adjust the dosage for renal impairment.

No signs of infection
Imbalanced nutrition: less than body requirements related to catabolic state, anorexia, and malnutrition associated with acute renal failure

Maintaining adequate nutrition
  • Work collaboratively with dietitian to regulate protein intake according to impaired renal function because metabolites that accumulate in blood derive almost entirely from protein catabolism.
  • Offer high-carbohydrate feedings because carbohydrates have a greater protein-sparing power and provide additional calories.
  • Weigh daily.
  • Monitor BUN, creatinine, electrolytes, serum albumin, prealbumin, total protein, and transferrin.
  • Be aware that food and fluids containing large amounts of sodium, potassium, and phosphorus may need to be restricted.
  • Prepare for hyperalimentation when adequate nutrition cannot be maintained through the GI tract.

Food intake adequate, maintaining weight
Risk for injury related to GI bleeding
Preventing GI bleeding
  • Examine all stools and emesis for gross and occult blood.
  • Administer H2-receptor antagonist, such as cimetidine (Tagamet) or ranitidine (Zantac), or nonaluminum or magnesium antacids as prophylaxis for gastric stress ulcers. If H2-receptor antagonist is used, care must be taken to adjust the dose for the degree of renal impairment.
  • Prepare for endoscopy when GI bleeding occurs

Stools heme negative
Disturbed thought processes related to the effects of uremic toxins on the central nervous system (CNS)

Preserving neurologic function
  • Speak to the patient in simple orienting statements, using repetition when necessary.
  • Maintain predictable routine, and keep change to a minimum.
  • Watch for and report mental status changes somnolence, lassitude, lethargy, and fatigue progressing to irritability, disorientation, twitching, seizures.
  • Correct cognitive distortions.
  • Use seizure precautions ”padded side rails, airway and suction equipment at bedside.
  • Encourage and assist patient to turn and move because drowsiness and lethargy may prevent activity.
  • Use music tapes to promote relaxation.
  • Prepare for dialysis, which may help prevent neurologic complications.

Appears more alert, sleeps less during the day

Nursing Key outcomes Nursing Care Plans for Acute Renal Failure 
Key outcomes for ARF, Patient will: 

  • Perform activities of daily living without excessive fatigue or exhaustion. 
  • Maintain hemodynamic stability. 
  • Achieving fluid and electrolyte balance. 
  • Preserving neurological function 
  • Remain free from signs or symptoms of circulatory overload. 
  • Verbalize the importance of balancing activities with adequate rest periods. 
  • Discuss fears or concerns. 
  • Preventing Gastro intestinal GI bleeding 
  • Verbalize appropriate food choices according to his prescribed diet. 
  • Patient’s oral mucous membrane will remain intact. 
  • The patient’s skin integrity will remain intact. 
  • Demonstrate skill in managing the urinary elimination problems. 
  • Maintain adequate urine output. 
  • The patient will remain free from signs or symptoms of infection. 
  • Family members will verbalize the effect the patient’s condition has on the family unit. 
  • The patient will avoid or minimize complications. 

Patient Teaching and Home Healthcare Guidelines Nursing Care Plans for ARF 
Every patient with Acute Renal Failure ARF need to understanding of renal function, signs and symptoms of Acute Renal Failure. Patients who have not recovered viable renal function need to understand that their condition may persist and even become chronic. And who have recovered viable renal function still need to be monitored by a nephrologists and If chronic renal failure is suspected, further outpatient treatment and monitoring are needed 

  • Explain that she or he may be more susceptible to infection than previously. 
  • Reassure the patient and family by clearly explaining all diagnostic tests, treatments, and procedures 
  • Teach the patient or significant others about all medications, including dosage, potential side effects, and drug interactions. 
  • Explain that the patient should tell the healthcare professional about the medications if the patient needs treatment such as dental work or if a new medication is added. 
  • Explain that ongoing medical assessment is required to check renal function. 
  • Explain all dietary and fluid restrictions. Note if the restrictions are life-long or temporary. 
  • Discuss with significant others the lifestyle changes that may be required with chronic renal failure 
  • Tell the patient about his prescribed medications, and stress the importance of complying with the regimen. 
  • Stress the importance of following the prescribed diet and fluid allowance. 
  • Instruct the patient to weigh him daily and report sudden increase of weight. 
  • Advise the patient against overexertion. If he becomes dyspneic or short of breath during normal activity, tell him to report it to his physician. 
  • Teach the patient how to recognize edema, and report this finding to the physician.