Nursing diagnoses

When caring for patients with cardiovascular disorders, you’ll find that you can use several nursing diagnoses frequently. These commonly used nursing diagnoses appear below, along with appropriate nursing interventions and rationales. See NANDA-I taxonomy II by domain, for the complete list of NANDA diagnoses.

Cardiovascular disorders: Activity intolerance

Related to an imbalance between oxygen supply and demand, Activity intolerance may be associated with such conditions as acute MI, valvular disorders, heart failure, peripheral vascular disorders, and other ailments.

Cardiovascular disorders: Expected outcomes

  • Patient states a desire to increase his activity level.
  • Patient identifies controllable factors that cause fatigue.
  • Patient demonstrates skill in conserving energy while carrying out activities of daily living (ADLs) to tolerance level.

Cardiovascular disorders: Nursing interventions and rationales

  • Discuss with the patient the need for activity, which will improve physical and psychosocial well-being.
  • Identify activities the patient considers desirable and meaningful to enhance their positive impact.
  • Encourage the patient to help plan activity progression. Make sure you include activities he considers essential to help compliance.
  • Instruct and help the patient to alternate periods of rest and activity to reduce the body’s oxygen demand and prevent fatigue.
  • Identify and minimize factors that diminish exercise tolerance to help increase activity level.
  • Monitor physiologic responses to increased activity (including respirations, heart rate and rhythm, and blood pressure) to ensure they return to normal a few minutes after exercising.
  • Teach the patient how to conserve energy while performing ADLs — for example, sitting in a chair while dressing, wearing lightweight clothing that fastens with Velcro or a few large buttons, and wearing slip-on shoes. These measures reduce cellular metabolism and oxygen demand.

Energy boost

Focus Topic: Cardiovascular disorders

  • Demonstrate exercises for increasing strength and endurance, which will improve breathing and gradually increase activity level.
  • Support and encourage activity to the patient’s level of tolerance to help develop his independence.
  • Before discharge, formulate a plan with the patient and his caregivers that will enable the patient to continue functioning at maximum activity tolerance or to gradually increase the tolerance. For example, teach the patient and his caregivers how to monitor the patient’s pulse during activities; recognize the need for oxygen, if prescribed; and use oxygen equipment properly. Participation in planning encourages patient satisfaction and compliance.

Cardiovascular disorders: Decreased cardiac output

Related to reduced stroke volume, Decreased cardiac output may be associated with such conditions as angina, bacterial endocarditis, heart failure, MI, valvular heart disease, and other ailments.

Cardiovascular disorders: Expected outcomes

  • Patient maintains hemodynamic stability.
  • Patient exhibits no arrhythmias.
  • Patient maintains adequate cardiac output.

Cardiovascular disorders: Nursing interventions and rationales

  • Monitor and record level of consciousness (LOC), heart rate and rhythm, oxygen saturation (using pulse oximetry), and blood pressure at least every 4 hours, or more often if necessary, to detect cerebral hypoxia possibly resulting from decreased cardiac output.
  • Auscultate heart and breath sounds at least every 4 hours. Report abnormal sounds as soon as they develop. Extra heart sounds may indicate early cardiac decompensation. Adventitious breath sounds may indicate pulmonary congestion and decreased cardiac output.
  • Measure and record intake and output. Reduced urine output without reduced fluid intake may indicate reduced renal perfusion, possibly from decreased cardiac output.
  • Promptly treat life-threatening arrhythmias to avoid the risk of death.
  • Weigh the patient daily before breakfast to detect fluid retention.
  • Inspect for pedal or sacral edema to detect venous stasis and decreased cardiac output.

Getting a facial

Focus Topic: Cardiovascular disorders

  • Provide skin care every 4 hours to enhance skin perfusion and venous flow.
  • Gradually increase the patient’s activities within limits of the prescribed heart rate to allow the heart to adjust to increased oxygen demand. Monitor pulse rate before and after activity to compare rates and gauge tolerance.
  • Plan the patient’s activities to avoid fatigue and increased myocardial workload.
  • Maintain dietary restrictions as ordered to reduce complications and the risk of cardiac disease.
  • Teach the patient stress-reduction techniques to reduce anxiety and provide a sense of control. (See Biofeedback.)
  • Explain all procedures and tests to enhance understanding and reduce anxiety.
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Biofeedback

Focus Topic: Cardiovascular disorders

Cardiovascular disorders

 

Teaching an old dog new tricks

Focus Topic: Cardiovascular disorders

  • Teach the patient about chest pain and other reportable symptoms, prescribed diet, medications (name, dosage, frequency, therapeutic effects, and adverse effects), prescribed activity level, simple methods for lifting and bending, and stress-reduction techniques. These measures involve the patient and his family in care.
  • Carry out the care plan, as ordered. Collaborative practice enhances overall care.
  • Administer oxygen as ordered to increase the supply to the myocardium.

Cardiovascular disorders: Deficient knowledge

Related to heart disease, Deficient knowledge can apply to a particular disorder or the risk factors related to cardiovascular disease.

Cardiovascular disorders: Expected outcomes

  • Patient expresses an interest in learning new behaviors.
  • Patient sets realistic learning goals.
  • Patient practices new health-related behaviors during hospitalization (for example, selects appropriate diet, weighs himself daily, and monitors intake and output).

Cardiovascular disorders: Nursing interventions and rationales

  • Establish an environment of mutual trust and respect to enhance learning. Comfort with growing self-awareness, ability to share this awareness with others, receptiveness to new experiences, and consistency between actions and words form the basis of a trusting relationship.
  • Help the patient develop goals for learning. Involving him in planning meaningful goals will encourage follow-through.
  • Select teaching strategies (discussion, demonstration, role-playing, or visual materials) appropriate for the patient’s individual learning style (specify) to enhance teaching effectiveness.
  • Teach skills that the patient must use every day. Have him demonstrate each new skill to help him gain confidence.
  • Have the patient incorporate learned skills into his daily routine during hospitalization (specify skills) to allow him to practice new skills and receive feedback.
  • Provide the patient with the names and telephone numbers of resource people or organizations to provide continuity of care and follow-up after discharge.
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