Goals:
Short-term goal: Patient will display blood pressure within acceptable limits, dysrhythmias controlled, and no symptoms of failure by the end of the shift.
Long-term goal: Patient will participate in activities that help to reduce cardiac workload.
Interventions:
1. Inspect skin for signs of cyanosis and pallor: Pallor is indicative of diminished peripheral perfusion and can be seen with inadequate cardiac output, vasoconstriction, and anemia. Cyanosis may develop in unruly HF.
2. Monitor urine output: Kidneys respond to reduced cardiac output by retaining water and sodium. There will be decreased output and concentrated urine.
3. Monitor BP: the body may no longer be able to compensate, and profound hypotension may occur.
Evaluation:
1. The goal was achieved by inspecting skin for pallor and cyanosis, and there were no signs of pallor and cyanosis.
2. The goal was achieved by monitoring urine output, and there was an adequate amount of urine output.
3. The goal was achieved by monitoring blood pressure and the result was stable.
Patient education needs for consideration:
1. recognize signs and symptoms of orthostatic hypotension and how to prevent them
2. Take pulse rate each day before taking medications (if appropriate). Know the parameters that your health care provider wants for your heart rate.
3. Follow up with the healthcare provider on regular basis.
Goals:
·Short-term goal: Patient identifies factors that improve circulation during the hospital stay.
·Long-term goal: Patient identifies necessary lifestyle changes.
Interventions:
1. Assist with position changes. – Gently repositioning patient from a supine to sitting/standing position can reduce the risk of orthostatic BP changes. Older patients are more susceptible to such drops of pressure with position changes.
2. Promote active/passive ROM exercises. - Exercise prevents venous stasis and further circulatory compromise.
3. Administer medications as prescribed to treat the underlying problem. - Peripheral vasodilators: these enhance arterial dilation and improve peripheral blood flow.
Evaluation:
1. The goal was achieved by assist with position changes which reduce the risk for orthostatic BP change.
2. The goal was achieved by promoting ROM exercises which prevented venous stasis and circulatory compromise.
3. The goal was achieved by administering peripheral vasodilators as prescribed which enhance arterial dilation and improve peripheral blood flow.
Patient education needs for consideration:
1. Do not elevate legs above the level of the heart. This decrease arterial blood supply to the legs.
2. Provide much attention to foot care. Refer to a podiatrist if a patient has a foot or nail abnormality. Foot care can prevent further injury.
3. Keep patient warm, and have patient wear socks and shoes or sheepskin-lined slippers when mobile. Do not apply heat. This keeps extremities warm to maintain vasodilatation and blood supply.
Goals:
Short-term goal: Patient describes own anxiety and coping patterns by end of the shift.
· Long-term goal: Patient has vital signs that reflect baselin
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