Provide the data requested below. In addition, following each factor you have listed, identify whether it inhibits (I), promotes (P), or has little effect on
learning (NA).
Individual’s initials X.X Date of care 2/19/2022
Presence of Pain No complaints (p)
Physiological: Age 61(p)
Level of orientation A+O x 4 (p)
Level of illness (chronic or acute) Chronic (i)
Energy level Low energy (i)
Neurosensory:
Vision wears glasses (i)
Hearing no deficits (p)
Touch Perception WNL (na)
Motor skills WNL (p)
Cognitive level:
Highest grade level completed Highschool (na)
Reading ability age appropriate (p)
Language fluency English (p)
Developmental Level (child, adolescent, adult, elderly adult) adult (p)
Socioeconomic:
Marital Status married (na)
Nature of involvement of family/significant others in care/teaching of individual Spouse and daughter visit and help pt. Pt resides in adult living.(p)
Occupation cashier at Storm Products (na)
Financial status Middle class (na)
Psychological:
Individual’s level of motivation as evidenced by statements and behaviors
Patient has motivation to stay healthy AEB hygiene, active ADL’s, and participation in care (p)
Presence of anxiety or fear patient has anxiety (i)
Use of defense mechanisms none observed (na)
Cultural:
Ethnic group white—non Hispanic (na)
Religion Roman Catholic (na)
Non-conventional beliefs related to illness and provision of care none (na)
Environmental:
Describe setting (room well lit, comfortably warm, free from distractions)
Well lit—sun, comfortably warm, private, clean, quiet (p)
Using data collected from your Assessment of the Learner summarize the following:
a. Factors promoting learning:
 Age of 62
 No complaints of pain
 LOC, A+O x 4
 No hearing deficits
 Motor skills, WNL
 Reading ability, age appropriate
 English language
 Developmental level, adult
 Family involvement, spouse and daughter
 Level of motivation, appropriate health maintenance
 Environment
a. Factors inhibiting learning:
 Chronic illness
 Low energy
 anxiety
List community resources available to client:
Social worker, mental health treatment, Medicaid, group therapy
Instructional Methods:
Instructional Aids:
Discussion X
Audio-visual X
Demonstration X
Handout X
Return Demonstration _____
Photo_____
Resources: Provide full reference information. Must use at least 2 of those listed below.
Textbook
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2006). Nursing care plans: Guidelines for individualizing patient care. F.A. Davis.
Doenges, Marilynn E; Moorhouse, Mary Frances; Murr, Alice C. Nursing Diagnosis Manual Planning, Individualizing, and Documenting Client Care. F.A. Davis
Company. Kindle Edition.
Internet
For all your nursing needs. Nurseslabs. (n.d.). Retrieved February 24, 2022, from https://nurseslabs.com/
Pamphlet__________
Goal #1: The client will increase knowledge of
his respiratory condition.
Information Provided
Write actual words you will use to provide
information.
Evaluation
Was the initial individual assessment accurate?
Were the outcome criteria appropriate to the
learning goal?
Outcome Criteria
1. The client will be able to describe, in SIMPLE
terms the basic anatomy and physiology and
major aspects of his respiratory deficit.
Asthma: Chronic, reversible inflammation of the
airways caused by a reaction of the airways to various
stimuli.
Chronic bronchitis: Inflammation and scarring of the
lining of the bronchi.
Chronic obstructive pulmonary disease (COPD):
Disease state characterized by an airflow limitation
that is not fully reversible. It is usually progressive and
associated with an abnormal inflammatory response
to noxious particles or gases (Global Initiative for
Chronic Obstructive Lung Disease [GOLD], 2007).
Emphysema: Destruction of the alveoli, which leads to
overdistention of the air spaces. Damage is
irreversible.
Pathophysiology
 Chronic obstructive pulmonary disease
(COPD): chronic obstructive bronchitis and
emphysema
o Chronic airflow limitations (CAL):
caused by a mixture of small airway
disease (obstructive bronchiolitis) and
parenchymal destruction
(emphysema)
o Airway inflammation: causes
structural changes, narrowing of
lumina, and loss of elastic recoil in
parenchyma
 Asthma (also called chronic reactive airway
disease)
o Chronic inflammatory disorder—
episodic exacerbations of reversible
inflammation and hyperreactivity and
variable constriction of bronchial
Was the teaching method appropriate?
Which outcomes were achieved? Which were not
achieved, if any? What follow up may be needed?
The initial individual assessment was accurate.
The outcome criteria were appropriate to the
learning goal. The teaching method was
appropriate. All outcomes achieved. No follow-up
needed.
smooth muscle, hypersecretion of
mucus, and edema
2. The client will be able to identify risk factors
for COPD.
Goal #2: The client will modify his lifestyle
based upon his risk factors.
Outcome Criteria
1.The client will be able
to list his specific risk factors, if any.
Etiology
 COPD
o Risk factors: smoking (primary
irritant), air pollution, secondhand
smoke, history of childhood
respiratory infections, heredity—1antitrypsin deficiency
o Acute exacerbations usually due to
pulmonary infections
 Asthma
o Tends to be acute and intermittent or
episodic
o Genetic and environmental:
household substances (such as dust
mites, pets, cockroaches, mold),
pollen, foods, latex, emotional
upheaval, air pollution, cold weather,
exercise, chemicals, medications, viral
infections
Information Provided
Write actual words you will use to provide
information.
Risk factors
 COPD
o alpha-1-antitrypsin deficiency
 Asthma
o Genetic
o Environmental
Reducing Risk Factors
The initial individual assessment was accurate.
The outcome criteria were appropriate to the
learning goal. The teaching method was
appropriate. All outcomes achieved. No follow-up
needed.
Evaluation
Was the initial individual assessment accurate?
Were the outcome criteria appropriate to the
learning goal?
Was the teaching method appropriate?
Which outcomes were achieved? Which were not
achieved, if any? What follow up may be needed,
if any?
The initial individual assessment was accurate.
The outcome criteria were appropriate to the
learning goal. The teaching method was
appropriate. All outcomes achieved. No follow-up
needed.
2. The client will identify specific ways to
reduce his risk factors.


COPD
o N/A
Asthma
o Avoid environmental triggers
Goal #3 The client will comply with the
prescribed medical management.
Information Provided
Write actual words you will use to provide
information.
Outcome Criteria
Albuterol-ipratopium (DUO-NEB) 2.5-0.5 (3) mg/3mL
nebulizer solution 3mL PRN
1.The client will identify dose, frequency,
action, and side effects of his drug therapy.
Action:
Binds to beta2-adrenergic receptors in airway smooth
muscle, leading to activation of adenyl cyclase and
increased levels of cyclic-3, 5-adenosine
monophosphate (cAMP). Increases in cAMP activate
kinases, which inhibit the phosphorylation of myosin
and decrease intracellular calcium. Decreased
intracellular calcium relaxes smooth muscle airways.
Relaxation of airway smooth muscle with subsequent
bronchodilation. Relatively selective for beta2
(pulmonary) receptors.
Side Effects:
nervousness, restlessness, tremor, headache, chest
pain, palpitations
Alprazolam (Xanax) tablet 0.25 mg 2 x daily
Action:
Acts at many levels in the CNS to produce anxiolytic
effect. May produce CNS depression. Effects may be
mediated by GABA, an inhibitory neurotransmitter.
The initial individual assessment was accurate.
The outcome criteria were appropriate to the
learning goal. The teaching method was
appropriate. All outcomes achieved. No follow-up
needed.
Evaluation
Was the initial individual assessment accurate?
Were the outcome criteria appropriate to the
learning goal?
Was the teaching method appropriate?
Which outcomes were achieved? Which were not
achieved, if any? What follow up may be needed,
if any?
The initial individual assessment was accurate.
The outcome criteria were appropriate to the
learning goal. The teaching method was
appropriate. All outcomes achieved. HCP followup necessary for physical assessment and
diagnostic studies for potential medication side
effects.
Side Effects:
dizziness, drowsiness, lethargy
Amiodarone (pacerone) tablet 400 mg 2 x daily
Action:
Prolongs action potential and refractory period.
Inhibits adrenergic stimulation. Slows the sinus rate,
increases PR and QT intervals, and decreases
peripheral vascular resistance (vasodilation).
Side Effects:
dizziness, fatigue, malaise, corneal microdeposits,
bradycardia, hypotension, anorexia, constipation,
nausea, vomiting, photosensitivity, hypothyroidism,
ataxia, involuntary movement, parethesia, peripheral
neuropathy, poor coordination, tremor
Dapagliflozin propanediol (farxiga) tablet 10 mg daily
Action:
Inhibits subtype 2 of the sodium-glucose transport
proteins (SGLT2) which are responsible for at least
90% of the glucose reabsorption in the kidney.
Blocking this transporter mechanism causes blood
glucose to be eliminated through the urine.
Side Effects:
Hypoglycemia, urinary tract infection, volume
depletion, DKA in type 1 diabetics
Fluticasone-vilanterol (breo ellipta) 100-25 mcg/inh
inhaler 1 puff at bedtime
Action:
Potent, locally acting anti-inflammatory and immune
modifier.
Side Effects:
Headache, dysphonia, hoarseness
Furosemide (Lasix) tablet 60 mg daily
Action:
Inhibits the reabsorption of sodium and chloride from
the loop of Henle and distal renal tubule. Increases
renal excretion of water, sodium, chloride,
magnesium, potassium, and calcium. Effectiveness
persists in impaired renal function.
Side Effects:
Dehydration, hypocalcemia, hypochloremia,
hypokalemia, hypomagnesemia, hyponatremia,
hypovolemia, metabolic alkalosis
Heparin 25,000 units in NaCL 0.45% 250 mL solution
675.6 units/hr continuous infusion
Action:
Potentiates the inhibitory effect of antithrombin on
factor Xa and thrombin. In low doses, prevents the
conversion of prothrombin to thrombin by its effects
on factor Xa. Higher doses neutralize thrombin,
preventing the conversion of fibrinogen to fibrin.
Side Effects:
Bleeding, HIT, anemia
Hydrocortisone (anusol-hc) suppository 25 mg daily
&
Methylprednisolone sodium succinate (solu-medrol)
injection 20 mg every 12 hrs
Action:
In pharmacologic doses, all agents suppress
inflammation and the normal immune response. All
agents have numerous intense metabolic effects
Side Effects:
Depression, euphoria, peptic ulceration, hypertension,
anorexia, nausea, acne, decreased wound healing,
ecchymoses, fragility, hirsutism, petechiae, adrenal
suppression, muscle wasting, osteoporosis, cushingoid
appearance
Lispro insulin low s/s 1-5 units 4 x daily
Action:
Lower blood glucose by stimulating glucose uptake in
skeletal muscle and fat, inhibiting hepatic glucose
production. Other actions: inhibition of lipolysis and
proteolysis, enhanced protein synthesis.
Side Effects:
Hypoglycemia
Metroprolol succinate (toptol xl) ER partial tablet
37.5 mg daily
Action:
Blocks stimulation of beta1(myocardial)-adrenergic
receptors. Does not usually affect beta2(pulmonary,
vascular, uterine)-adrenergic receptor sites.
Side Effects:
Fatigue, weakness, bradycardia, pulmonary edema,
erectile dysfunction
Pancrelipase (lip-prot-amyl) 10440-39150 units 1
tablet, sodium bicarbonate 650 mg slurry PRN
Action:
Contains lipolytic, amylolytic, and proteolytic activity.
Side Effects:
Abdominal pain, diarrhea, nausea, stomach cramps
Paroxetine (paxil) tablet 10 mg
Action:
Inhibits neuronal reuptake of serotonin in the CNS,
thus potentiating the activity of serotonin; has little
effect on norepinephrine or dopamine.
Side Effects:
Neuroleptic malignant syndrome, suicidal thoughts,
anxiety, dizziness, drowsiness, headache, insomnia,
weakness, constipation, diarrhea, dry mouth, nausea,
ejaculatory disturbance
Polyethylene glycol (miralax) oral packet 17 g daily
Action:
Polyethylene glycol (PEG) in solution acts as an
osmotic agent, drawing water into the lumen of the GI
tract.
Side Effects:
urticaria, abdominal bloating, cramping, flatulence,
nausea
Sacubitril-valsartan (entresto) 97-103 mg tablet 2 x
daily
Action:
The sacubitril/valsartan drug inhibits neprilysin and
blocks angiotensin II type-I receptor, increasing the
levels of peptides degraded by neprilysin. Valsartan
inhibits the effects of angiotensin II by blocking the
AT1 receptor and by inhibiting the release of
angiotensin II-dependent aldosterone.
Side Effects:
Abdominal pain, blurred vision, confusion, difficult
breathing, dizziness, postural hypotension, irregular
heartbeat, nausea, vomiting, nervousness, peripheral
neuropathy, diaphoresis, fatigue, weakness
Tiotropium bromide monohydrate (Spiriva)
inhalation capsule 18 mcg daily
Action:
Acts as anticholinergic by selectively and reversibly
inhibiting M3 receptors in smooth muscle of airways.
Side Effects:
Dry mouth, constipation, angioedema
Vitamin B-1 (thiamine) tablet 100 mg daily
Action:
May suppress excess levels of tumor necrosis
factoralpha (TNF-alpha) in patients with ENL and alter
leukocyte migration by altering characteristics of cell
surfaces.
Side Effects:
Dizziness, drowsiness, rash, peripheral neuropathy
2. The client will identify prescribed limitations
in physical activity including return to work,
activities of daily living, and sexual activity
Prescribed limitations
 Activity as tolerated
Included
3. The client will identify foods to be INCLUDED
 Parenteral tube feedings
and EXCLUDED on his prescribed diet.
 Protein supplements
 Energy supplements
 Fresh and frozen vegetables
 Fresh or frozen fruits
 Grains and beans
 Starchy vegetables
 Fresh or frozen meat, poultry, and fish
 Healthy fats (olive oil)
 “Low-sodium” labeled foods
The initial individual assessment was accurate.
The outcome criteria were appropriate to the
learning goal. The teaching method was
appropriate. All outcomes achieved. Follow-up
needed with HCP if any changes occur.
The initial individual assessment was accurate.
The outcome criteria were appropriate to the
learning goal. The teaching method was
appropriate. All outcomes achieved. Follow-up
with dietician needed.
Excluded
 High Sodium foods and beverages (< 2g/day)
 Fast food
 Frozen dinners
 Boxed meals
 Processed meats
 Canned products
 Cheese and dairy
 Sauces/condiments
 Seasonings
 Pickled vegetables
Goal #4: The client will recognize impending
complications related to his cardiac condition.
Information Provided
Write actual words you will use to provide
information.
Evaluation
Was the initial individual assessment accurate?
Were the outcome criteria appropriate to the
learning goal?
Was the teaching method appropriate?
Which outcomes were achieved? Which were not
achieved, if any? What follow up may be needed,
if any?
Outcome Criteria
Activity/Rest
 Fatigue
 Restlessness, insomnia
 General debilitation or loss of muscle mass
Circulation
 Elevated blood pressure (BP)
 Elevated heart rate or severe tachycardia,
dysrhythmias
 Distended neck veins, with advanced disease
 Dependent edema, which may not be related
to heart disease
 Faint heart sounds due to increased
anteroposterior (AP) chest diameter
 Skin color and mucous membranes may be
pale or bluish and cyanotic, clubbing of nails
and peripheral cyanosis, pallor (can indicate
anemia)
The initial individual assessment was accurate.
The outcome criteria were appropriate to the
learning goal. The teaching method was
appropriate. All outcomes achieved. Follow-up
needed if any life threatening symptoms occur.
1. The client will be able to list signs and
symptoms related to his respiratory condition
and what actions to take.
Ego Integrity
 Anxious, fearful, irritable behavior, emotional
distress
 Apathy, change in alertness, dull affect,
withdrawal
Food/Fluid
 Poor skin turgor
 Dependent edema
 Diaphoresis
 Abdominal palpation may reveal
hepatomegaly
Hygiene
 Poor hygiene
Respiration
 Respirations are usually rapid and may be
shallow:
 Prolonged expiratory phase with grunting,
pursed-lip breathing (emphysema)
 Assumption of three-point (“tripod”) position
for breathing— especially with acute
exacerbation of chronic bronchitis
 Use of accessory muscles for respiration, such
as elevated shoulder girdle, retraction of
supraclavicular fossae, flaring of nares
 Chest may appear hyperinflated with
increased AP diameter (barrel-shaped),
minimal diaphragmatic movement
 Breath sounds may be faint with expiratory
wheezes (emphysema):
o Scattered, fine, or coarse moist
crackles (bronchitis)
o Rhonchi, wheezing throughout lung
fields on expiration, and possibly
during inspiration, progressing to
diminished or absent breath sounds
(asthma)
 Percussion may reveal hyperresonance over
lung fields (air-trapping with emphysema) or



dullness over lung fields (consolidation, fluid,
mucus)
Difficulty speaking sentences of more than
four or five words at one time, loss of voice
Color: Pallor, with cyanosis of lips, nailbeds;
overall duskiness; ruddy color (chronic
bronchitis, “blue bloaters”):
o Normal skin color despite abnormal
gas exchange and rapid respiratory
rate (moderate emphysema, known as
“pink puffers”)
Clubbing of fingernails (not characteristic of
emphysema, and if present, should alert
clinician to another condition such as
pulmonary fibrosis, cystic fibrosis, lung cancer,
or asbestosis)
Safety
 Flushing, perspiration (asthma)
Sexuality
 Decreased libido
Social Interaction
 Inability to converse or maintain voice
because of respiratory distress
 Limited physical mobility
 Neglectful relationships with other family
members
 Inability to perform or inattention to
employment responsibilities, absenteeism,
confirmed disability
TRITON COLLEGE
NURSING CARE PLAN MAP—NUR 255
Provide the essential data in the rectangle for your assigned patient as if you were giving report to the next shift.
Initials T.M.
Age 61
Reason for hospitalization Bright red blood per rectum; paroxysmal atrial fibrillation
Surgical interventions and Dates
PEG TUBE 10/11/21
Past History
 pulmonary module, right
 alpha-1-antitrypsin deficiency
 COPD, severe
 Osteoporosis
 Heart failure
 Anxiety
 Vitamin D deficiency
 Protein-calorie deficit
 Asthma
 Congestive heart failure
 Hyponatremia
 Respiratory failure with hypoxia
 SOB
 Moderate episode of recurrent major depressive disorder
 HFrEF
Oxygen
4 L/min nasal cannula
Nutrition
 PEG tube for protein malnutrition, tube feeding daily
o Nepro
o 90mL/hr x7 hours (nocturnal)
o Run TF from 8pm-3pm daily
o Flush with 60mL H2O before and after TF
 No added salt diet
Bowel/Bladder elimination
 Continent x2
 Bright red blood in stool x 1 month
Activity and Rest


Stand by assist, BRP
Active ROM
Protection
 Heels elevated
 Bed alarm refused
Senses
WNL
F&E, A-B
 WNL
 Hx hyponatremia
 Hx hypokalemia
 Hx hypoxia
Neuro Function
A+O x 4
Endocrine function
Steroid hyperglycemia
Psychosocial Modes
 Hx of depression and anxiety
 Lives at adult living center
 Wife and daughter are active in pt care
List the health problems identified by the physician for this patient. For each health problem, list the supporting and diagnostic results. List EVERY med
ordered to treat each of the health problems, its classification, action and desired outcome for this patient.
Health Problem
1. Anxiety
2. Protein-calorie malnutrition
3. Asthma
4. Congestive Heart Failure
5. COPD (emphysema)
6. Atrial Fibrillation
7. Steroid hyperglycemia
Supporting diagnostic Lab Results
Psychological evaluation
Pharmacological Intervention
Alprazolam tablet 0.25 mg 2 x daily PRN
Low BMI, total protein, albumin, and albumin/globulin
(A/G) ratio
PFT
Parenteral nutrition, Nepro
Albuterol-ipratropium (DUO-NEB) 2.5-0.5 (3)
mg/3mL nebulizer solution
ECG
Fluticasone-vilanterol 100-25 mcg/inh inhaler
1 puff
Furosemide tablet 60mg daily
PFT
Sacubitril-valsartan 97-103 mg per tablet 1 tablet
daily
Hydrocortisone suppository 25 mg daily
12 Lead EKG
Tiotropium bromide monohydrate inhalation
capsule 10mcg daily
Amiodarone tablet 400mg 2 x daily
High blood glucose
Metoprolol succinate ER partial tablet 37.5 mg
daily
Dapagliflozin propanediol 10 mg tablet daily
8. Blood Clot
Doppler
9. Depression
10. Constipation
Psychological evaluation
No BM x 1 week per pt
Lispro insulin low s/s 1-5 Units
4 x daily with meals and bedtime
Heparin 25,000 units in NaCl 0.45% 250 mL
infusion continuous 6.8 mL/hr, 12 Units/kg/hr
Paroxetine tablet 10mg daily
Polyethylene glycol oral packet 17 g daily
Develop a diagram to illustrate all connections between the health problems. Each problem is to be listed in a separate geometric shape. Draw lines and add
arrows to show connections between the problems and the direction of the connection. Label each line with a letter a,b,c and so on. For each line, explain the
relationship between the two health problems. How does one health problem relate to the other? How do the drugs being used to treat one health problem
affect the outcome of another problem? How does the presence of one health make it more difficult to manage another health problem?
Description of Relationships between Health Problems. Source with page no. for relationship/rationales MUST be included.
a. alpha-1-antitrypsin deficiency causes COPD
b. COPD causes respiratory failure and heart failure
c. Respiratory failure and heart failure causes depression and anxiety
d. Heart failure causes blood clot
e. Steroid medications causes steroid hyperglycemia
Rationale: based on risk factors and side effects
Mayo Foundation for Medical Education and Research. (n.d.). Mayo Clinic. Retrieved February 24, 2022, from https://www.mayoclinic.org/
List all nursing diagnoses with related (influencing) factors for this patient. There must be supporting data (defining characteristics) on the first page to
support the existence of each problem. You should be able to consolidate the data and related factors to define no more than 8 nursing diagnoses for even
the most acutely ill patient and still be inclusive of all needs. List the diagnoses in order of priority. Include potential nursing diagnoses that can be
supported by the data you have collected.
1. Ineffective Airway Clearance may be related to bronchospasm; increased production of secretions, thick, viscous secretions; decreased energy of fatigue
possibly evidenced by statement of difficulty breathing; changes in depth and rate of respirations, use of accessory muscles; abnormal breath sounds such as
wheezes, rhonchi, crackles; cough (persistent), with or without sputum production
2. Impaired Gas Exchange may be related to altered oxygen supply—obstruction of airways by secretions, bronchospasm, air-trapping; alveoli destruction
possibly evidenced by dyspnea; confusion, restlessness; inability to move secretions; abnormal ABGs—hypoxia and hypercapnia; changes in vital signs; reduced
tolerance for activity
3. Decreased Cardiac Output may be related to altered myocardial contractility, inotropic changes; alterations in rate, rhythm, electrical conduction; structural
changes, such as valvular defects and ventricular aneurysm possibly evidenced by increased heart rate (tachycardia), dysrhythmias, ECG changes; changes in BP
(hypotension, hypertension); extra heart sounds (S3, S4); decreased urine output; diminished peripheral pulses; cool, ashen skin and diaphoresis; orthopnea,
crackles, JVD, liver engorgement, edema; chest pain
4. Ineffective Peripheral Tissue Perfusion may be related to decreased blood flow and venous stasis (partial or complete venous obstruction) possibly evidenced
by tissue edema, pain; diminished peripheral pulses, slow or diminished capillary refill; skin color changes—pallor, erythema
5. Imbalanced Nutrition: Less than Body Requirements may be related to dyspnea, sputum production; medication side effects; anorexia, nausea or vomiting;
fatigue possibly evidenced by weight loss, loss of muscle mass, poor muscle tone; reported altered taste sensation, aversion to eating, lack of interest in food
6. Activity Intolerance may be related to imbalance between oxygen supply and demand; generalized weakness; prolonged bedrest, immobility possibly
evidenced by weakness, fatigue; changes in vital signs, presence of dysrhythmias; dyspnea; pallor, diaphoresis
7. Fatigue may be related to decreased metabolic energy production; increased energy requirements—hypermetabolic states, healing process; altered body
chemistry: medications possibly evidenced by overwhelming lack of energy, inability to maintain usual routines or accomplish routine tasks; lethargy, impaired
ability to concentrate
8. Anxiety may be related to unconscious conflict about essential goals and values of life; unmet needs Situational or maturational crises, stress Interpersonal
transmission and contagion of anxious feelings; threat of death—perceived or actual; threat to, or change in, health status—exposure to toxins, substance
abuse, progressive or debilitating disease, terminal illness; separation from support system; sensory impairment possibly evidenced by behavioral: expressed
concerns due to change in life events, diminished productivity, restlessness, extraneous movement, insomnia; affective: irritability, jittery, rattled, regretful,
distressed, apprehensive, worried, feelings of inadequacy, uncertainty, feelings of helplessness; physiological: Reports of increased tension, quivering voice,
trembling; sympathetic and parasympathetic: palpitations, urinary frequency, nausea; cognitive: blocking of thought, impaired attention, confusion,
forgetfulness, rumination, difficulty concentrating, focus on self, fight or flight behavior, dread of an identifiable problem recognized by client, fear of unspecific
consequences
Nursing Diagnosis and
Related (Influencing)
Factors
Supporting Data
(Defining Characteristics)
Short and Long-Term Goal with
Corresponding Criteria
Interventions and Rationale =
Scientific basis for EACH
Nursing action. Label Rationales
(R)
Evaluation
Goals met or not met?
Interventions appropriate?
Recommendations for other
interventions?
#1 Impaired Gas
Exchange
r/t alveoli destruction,
altered oxygen supply,
respiratory failure, heart
failure
Dyspnea, reduced
tolerance to activity, use
of accessory muscles,
hypoxia, irritability,
dysrhythmia
Short Term Goal:
Pt will: verbalize understanding
of oxygen supplementation and
other therapeutic interventions
before discharge
Short Term Goal Interventions:
Review oxygen-conserving
techniques (e.g., organizing
tasks before beginning; sitting
instead of standing to perform
tasks; eating small meals;
performing slower, purposeful
movements)
(R) to reduce oxygen demands.
Reinforce need for adequate
rest, while encouraging activity
and exercise (e.g., upper and
lower extremity endurance and
strength training, and flexibility)
(R) to decrease dyspnea and
improve quality of life.
Emphasize the importance of
good general nutrition
(R) for improving stamina and
reducing the work of breathing.
Long Term Goal:
Pt will: maintain clear lung fields
and remain free of signs of
respiratory distress
Long Term Goal Interventions:
Assess respiratory rate and
depth. Note use of accessory
muscles, pursed-lip breathing,
and inability to speak or
converse.
(R) Useful in evaluating the
degree of respiratory distress
and chronicity of the disease
process.
Goals met. Interventions were
appropriate. No current
recommendations.
Elevate head of bed and assist
client to assume position to ease
work of breathing. Include
periods of time in prone
position as tolerated. Encourage
deep, slow or pursed lip
breathing as individually needed
and tolerated.
(R) Oxygen delivery may be
improved by upright position
and breathing exercises to
decrease airway collapse,
dyspnea, and work of breathing.
Note: Recent research supports
use of prone position to
increase PaO2.
Encourage frequent position
changes, deep-breathing
exercises or directed coughing,
use of incentive spirometer, and
chest physiotherapy as
indicated.
(R) Promotes optimal chest
expansion, mobilization of
secretions, and oxygen
diffusion.
Evaluate level of activity
tolerance. Provide calm, quiet
environment. Limit client’s
activity or encourage bedrest or
chair rest during acute phase.
Have client resume activity
gradually and increase as
individually tolerated.
(R) During severe, acute, or
refractory respiratory distress,
client may be totally unable to
perform basic self-care activities
because of hypoxemia and
dyspnea. Rest interspersed with
care activities remains an
important part of treatment
regimen. An exercise program is
aimed at improving aerobic
capacity and functional
performance, increasing
endurance and strength without
causing severe dyspnea, and can
enhance sense of well-being.
#2 Decreased Cardiac
Output
r/t decreased
oxygenation, increased
afterload, decreased
preload, CHF
Heart palpitations,
fatigue, dyspnea,
orthopnea, anxiety,
dysrhythmia
Short Term Goal:
Pt will: report or demonstrate
decreased episodes of dyspnea,
angina, and dysrhythmias before
discharge
Short Term Goal Interventions:
Discuss significant
signs/symptoms that need to be
reported to healthcare provider,
such as
(R) unrelieved or increased
chest pain, dyspnea, fever,
swelling of ankles, and sudden
unexplained cough—these are
all “danger signs” that require
immediate evaluation and
possible change of usual
therapies.
Provide instruction for home
monitoring of weight, pulse, and
blood pressure, as appropriate,
(R) to detect change and allow
for timely intervention.
Goals met. Interventions were
appropriate. No current
recommendations.
Long Term Goal Interventions:
Long Term Goal:
Pt will: display hemodynamic
stability (e.g., blood pressure,
cardiac output, urinary output,
peripheral pulses).
Minimize activities that can elicit
Valsalva response (e.g., rectal
straining, vomiting, spasmodic
coughing with suctioning,
prolonged breath-holding during
pushing stage of labor) and
encourage client to breathe
deeply in and out during
activities that increase risk of
Valsalva effect.
(R) Valsalva response to breathholding causes increased
intrathoracic pressure, reducing
cardiac output and blood
pressure.
Administer medications as
indicated (e.g., inotropic drugs
(R) to maintain systemic
perfusion and preserve endorgan performance,
antiarrhythmics to improve
cardiac output; diuretics to
reduce congestion by improving
urinary output; vasopressors
and/or dilators as indicated to
manage systemic effects of
vasoconstriction and low cardiac
output; pain medications and
anti-anxiety agents to reduce
oxygen demand and myocardial
workload; anticoagulants to
improve blood flow and prevent
thromboembolism). Note:
Studies show that some
antiarrhythmics have negative
inotropic effects, and some,
particularly the class I and class
III drugs, have proarrhythmic
effects. Amiodarone
(Cordarone) and dofetilide
(Tikosyn) are two antiarrhythmic
agents found to have neutral
effects on mortality in clinical
trials of patients with HF.