PATIENT CARE PLAN
STUDENT
Osmelvy Perez Sanchez
DATE
PATIENT INITIALS
AGE
SEX
OTHER MEDICAL DX
ADMITTING DX
DATE
NURSING DIAGNOSIS
(in priority order)
PATIENT-CENTERED
GOALS
NURSING
INTERVENTION
RATIONALE
EVALUATION
1. Impaired Gas Exchange related to decreased oxygenation and potential pulmonary edema.
2. Disturbed Sleep Pattern related to pain, anxiety, and hospital environment.
3. Risk for Infection related to invasive procedures and compromised immune response.
4. Risk for Decreased Cardiac Perfusion related to obstructed blood flow and possible clot formation.
5. Activity Intolerance related to decreased cardiac function and weakness.
1. Maintenance of optimal oxygen saturation levels
2. Empowering the patient and their family to participate in the self-management of respiratory health.
1. Reduction in pain and anxiety levels, promoting a conducive sleep environment.
2. Minimized disruptions during nighttime care routines.
1. Minimization of invasive procedures, when possible, to reduce infection risk.
2. Empowering the patient to participate in their infection prevention plan actively.
1. Increased patient understanding of signs and symptoms of impaired cardiac perfusion.
2. Empowering the patient to participate in their cardiac health management actively.
1. Reduction in feelings of weakness and fatigue during activity.
2. Empower the patient to engage in a safe, personalized exercise program.
1. Position the patient in a semi- or high-Fowler’s position to facilitate lung expansion and improve ventilation (Punia and Arora, 2023).
2. Educating the patient and family on breathing exercises and techniques to enhance lung function and manage dyspnea.
1. The patient can be placed in a semi-Fowler’s or high-Fowler’s posture to relieve pressure on the diaphragm, which promotes enhanced gas exchange and increased lung expansion.
2. Patient and family education empowers them to participate in their care actively, promoting adherence to treatment plans and better respiratory health management.
1. Measure and document oxygen saturation regularly to ensure it stays within the target range.
2. Discuss breathing techniques and ways to treat respiratory symptoms openly with the patient and their family to gauge their understanding.
1. Create a soothing sleep environment by minimizing noise and dimming lights during nighttime hours.
2. Coordinate nursing care activities to reduce unnecessary interruptions during nighttime hours.
1. A quiet and dimly lit environment during nighttime promotes a restful atmosphere and encourages better sleep quality.
2. Minimizing disruptions during nighttime care routines ensures uninterrupted sleep, essential for restorative rest.
1. To track advancements over time, track the patient’s sleep schedule and duration using a sleep diary or other assessment instrument.
2. Collaborate with the healthcare team to identify and address any systemic factors contributing to disturbed sleep patterns in the hospital environment. (Hillman et al.,2023).
1. Educate the patient and family about hand hygiene, wound care, and other infection prevention measures.
2. Collaborate with the healthcare team to minimize the number of invasive procedures or explore alternative, less invasive options. (Saba and Balwan, 2023).
1. By empowering individuals to actively participate in their care and lower the risk of infections, educating the patient and family about infection prevention methods.
2. Minimizing invasive procedures or seeking alternatives whenever possible reduces the opportunities for pathogens to enter the body.
1. Collaborate with the healthcare team to evaluate the necessity of invasive procedures and explore non-invasive options when appropriate.
2. Regularly review the patient’s infection risk status and assess the effectiveness of interventions in preventing infections.
1. Assist the patient in maintaining a safe and comfortable position to optimize cardiac output and perfusion.
2. Collaborate with the healthcare team to assess and manage underlying conditions contributing to decreased cardiac perfusion.
1. proper posture can increase cardiac output and blood flow in patients with impaired cardiovascular function. (Prandi et al.,2023).
2. Working with the medical staff ensures a thorough approach to the underlying reasons for poor myocardial perfusion.
1. Assess the patient’s comfort and positioning regularly and document any changes in cardiac function related to positional changes.
2. Collaborate with the healthcare team to review the patient’s overall progress in managing underlying conditions and improving cardiac perfusion.
1. Educate the patient about energy conservation techniques and pacing during daily activities to prevent excessive fatigue. (Lv et al.,2023).
2. Collaborate with physical therapists and other healthcare professionals to create a comprehensive rehabilitation plan.
1. Teaching energy conservation techniques enables the patient to accomplish tasks with less strain, minimizing fatigue and promoting independence.
2. Collaborating with other healthcare professionals ensures a multidisciplinary approach to addressing activity intolerance and provides a holistic care plan.
1. Review the patient’s adherence to energy conservation techniques and evaluate how effectively they implement them.
2. Collaborate with the healthcare team to evaluate the overall effectiveness of the rehabilitation plan in improving the patient’s activity tolerance and cardiac function.
References
Hillman, D. R., Carlucci, M., Charchaflieh, J. G., Cloward, T. V., Gali, B., Gay, P. C., … & Auckley, D. H. (2023). Society of Anesthesia and Sleep Medicine Position Paper on Patient Sleep During Hospitalization. Anesthesia & Analgesia, 136(4), 814-824. https://www.ingentaconnect.com/content/wk/ane/2023/00000136/00000004/art00027
Punia, S., & Arora, L. L. (2023). PULMONARY EDEMA. Advanced Anesthesia Review, 368. https://books.google.com/books?hl=en&lr=&id=exKrEAAAQBAJ&oi=fnd&pg=PA368&dq=Impaired+Gas+Exchange+related+to+decreased+oxygenation+and+potential+pulmonary+edema.&ots=BOGl5ZNkhy&sig=xwC0qx20ygoiJRucoTsnTAQVy_g
Prandi, F. R., Niv Granot, Y., Margonato, D., Belli, M., Illuminato, F., Vinayak, M., … & Lerakis, S. (2023). Coronary Obstruction during Valve-in-Valve Transcatheter Aortic Valve Replacement: Pre-Procedural Risk Evaluation, Intra-Procedural Monitoring, and Follow-Up. Journal of Cardiovascular Development and Disease, 10(5), 187. https://www.mdpi.com/2308-3425/10/5/187
Lv, M., Liao, L., Deng, Y., Jin, H., Chen, L., & Huang, Z. (2023). Risk factors for inspiratory muscle weakness in coronary heart disease. Heart & Lung, 60, 35-38. https://www.sciencedirect.com/science/article/pii/S0147956323000456
Saba, N., & Balwan, W. K. (2023). Study of Frequency, Epidemiology of Nosocomial Infections in Healthcare Centres. Saudi J Pathol Microbiol, 8(7), 160-166. https://www.researchgate.net/profile/Wahied-Balwan-2/publication/372140147_Study_of_Frequency_Epidemiology_of_Nosocomial_Infections_in_Healthcare_Centres/links/64a67870c41fb852dd55630e/Study-of-Frequency-Epidemiology-of-Nosocomial-Infections-in-Healthcare-Centres.pdf
