Knowledge Deficit | Nursing Care Plan for Pneumothorax

Nursing diagnois: Knowledge deficit related to lack of exposure to information

Possibly evidenced by

Expressions of concern, request for information

Recurrence of problem

Desired Outcomes/Evaluation Criteria—Client Will

Knowledge: Disease Process

Verbalize understanding of cause of problem (when known).

Identify signs or symptoms requiring medical follow-up.

Knowledge: Treatment Regimen

Follow therapeutic regimen and demonstrate lifestyle changes, if necessary, to prevent recurrence.

Nursing intervention with rationale:

1. Review pathology of individual problem.

Rationale: Information reduces fear of unknown. Provides knowledge base for understanding underlying dynamics of condition and significance of therapeutic interventions.

2. Identify likelihood for recurrence or long-term complications.

Rationale: Certain underlying lung diseases, such as severe COPD and malignancies, may increase incidence of recurrence. In otherwise healthy clients who suffered a spontaneous pneumothorax, incidence of recurrence is 10% to 50%. Those who have a second spontaneous episode are at high risk for a third incident (60%).

3. Review signs and symptoms requiring immediate medical evaluation, for example, sudden chest pain, dyspnea, air hunger, and progressive respiratory distress.

Rationale: Recurrence of pneumothorax and hemothorax requires medical intervention to prevent and reduce potential complications.

4. Review significance of good health practices, such as adequate nutrition, rest, and exercise.

Rationale: Maintenance of general well-being promotes healing and may prevent or limit recurrences.

5. Emphasize need for smoking cessation when indicated.

Rationale: Prevents recurrence of pneumothorax or respiratory complications, such as fibrotic changes.

Knowledge Deficit | Nursing Care Plan for Lung Cancer

Nursing diagnosis: Knowledge deficit related to lack of exposure, unfamiliarity with information or resources; information misinterpretation; lack of recall

Possibly evidenced by

Statements of concern; request for information

Inadequate follow-through of instruction

Inappropriate or exaggerated behaviors—hysterical, hostile, agitated, apathetic

Desired Outcomes/Evaluation Criteria—Client Will

Knowledge: Disease Process

Verbalize understanding of ramifications of diagnosis, prognosis, and possible complications.

Participate in learning process.

Knowledge: Treatment Regimen

Verbalize understanding of therapeutic regimen.

Correctly perform necessary procedures and explain reasons for the actions.

Initiate necessary lifestyle changes.

Nursing intervention with rationale:

1. Discuss diagnosis, current and planned therapies, and expected outcomes.

Rationale: Provides individually specific information, creating knowledge base for subsequent learning regarding home management. Radiation or chemotherapy may follow surgical intervention, and information is essential to enable the client and SO to make informed decisions.

2. Reinforce surgeon’s explanation of particular surgical procedure, providing diagram as appropriate. Incorporate this information into discussion about short- and long-term

recovery expectations.

Rationale: Length of rehabilitation and prognosis depend on type of surgical procedure, preoperative physical condition, and duration and degree of complications.

3. Discuss necessity of planning for follow-up care before discharge.

Rationale: Follow-up assessment of respiratory status and general health is imperative to assure optimal recovery. Also provides opportunity to readdress concerns or questions at a less

stressful time.

4. Identify signs and symptoms requiring medical evaluations, such as changes in appearance of incision, development of respiratory difficulty, fever, increased chest pain, and changes in appearance of sputum.

Rationale: Early detection and timely intervention may prevent or minimize complications.

5. Stress importance of avoiding exposure to smoke, air pollution, and contact with individuals with upper respiratory infections (URIs).

Rationale: Protects lung(s) from irritation and reduces risk of infection.

6. Review nutritional and fluid needs. Suggest increasing protein and use of high-calorie snacks as appropriate.

Rationale: Meeting cellular energy requirements and maintaining good circulating volume for tissue perfusion facilitate tissue regeneration and healing process.

7. Identify individually appropriate community resources, such as American Cancer Society, visiting nurse, social services, and home care.

Rationale: Agencies such as these offer a broad range of services that can be tailored to provide support and meet individual needs.

8. Help client determine activity tolerance and set goals.

Rationale: Weakness and fatigue should decrease as lung heals and respiratory function improves during recovery period, especially if cancer was completely removed. If cancer is advanced, it is emotionally helpful for client to be able to set realistic activity goals to achieve optimal independence.

9. Evaluate availability and adequacy of support system(s) and necessity for assistance in self-care and home management.

Rationale: General weakness and activity limitations may reduce individual’s ability to meet own needs.

10. Encourage alternating rest periods with activity and light tasks with heavy tasks. Stress avoidance of heavy lifting and isometric or strenuous upper body exercise. Reinforce physician’s

time limitations about lifting.

Rationale: Generalized weakness and fatigue are usual in the early recovery period but should diminish as respiratory function improves and healing progresses. Rest and sleep enhance

coping abilities, reduce nervousness (common in this phase), and promote healing. Note: Strenuous use of arms can place undue stress on incision because chest muscles

may be weaker than normal for 3 to 6 months following surgery.

Nursing Diagnosis for COPD and Asthma | Knowledge Deficit

Nursing diagnosis: deficient Knowledge [Learning Need] regarding condition, treatment, self-care, and discharge needs related to lack of information or unfamiliarity with information resources; information misinterpretation; lack of recall or cognitive limitation

Possibly evidenced by
Request for information
Statement of concerns and misconceptions
Inaccurate follow-through of instructions
Development of preventable complications

Desired Outcomes/Evaluation Criteria—Client Will
Knowledge: Illness Care
Verbalize understanding of condition and disease process and treatment.
Identify relationship of current signs and symptoms to the disease process and correlate these with causative factors.
Initiate necessary lifestyle changes and participate in treatment regimen.

Nursing care plan intervention with rationale:
1. Explain and reinforce explanations of individual disease process, including factors that lead to exacerbation episodes. Encourage client and SO to ask questions.
Rationale: Understanding decreases anxiety and can lead to improved participation in treatment plan.

2. Identify individual environmental factors such as excessively dry air, wind, temperature extremes, pollen, tobacco smoke, aerosol sprays, and air pollution that may trigger or aggravate condition. Encourage client and SO to explore ways to control these factors in and around the home and work setting.
Rationale: These can induce or aggravate bronchial irritation, leading to increased secretion production and airway blockage.

3. Review the harmful effects of smoking, and strongly advise cessation of smoking by client and SO. Provide information on QUITLINES, support groups, nicotine substitutes, and other resources that aid in smoking cessation.
Rationale: Cessation of smoking may slow or halt progression of COPD. Even when client wants to stop smoking, support groups and medical monitoring may be needed. Note: Research studies suggest that sidestream or secondhand smoke can be as detrimental as actually smoking.

4. Provide information about benefits of regular exercise while addressing individual activity limitations.
Rationale: Having this knowledge can enable client and SO to make informed choices and decisions to reduce client’s dyspnea, maximize functional level, perform most desired activities, and prevent complications. This may include alternating activities with rest periods to prevent fatigue, conserving energy during activities by pulling instead of pushing articles, sitting instead of standing while performing tasks; using pursed-lip breathing, side-lying position, and possible need for supplemental oxygen during sexual activity.

5. Discuss importance of regular medical follow-up care, when to notify healthcare professional of changes in condition, and periodic spirometry testing, chest x-rays, and sputum cultures.
Rationale: Monitoring disease process allows for alterations in therapeutic regimen to meet changing needs and may help prevent complications.

6. Review oxygen requirements and dosage for client who is discharged on supplemental oxygen. Discuss safe use of oxygen and refer to supplier as indicated.
Rationale: Reduces risk of misuse—too little or too much—and resultant complications. Promotes environmental and physical safety.

7. Instruct client and SO in use of NIPPV as appropriate. Problemsolve possible side effects, and identify adverse signs and symptoms such as increased dyspnea, fatigue, daytime drowsiness, or headaches on awakening.
Rationale: NIPPV may be used at night and periodically during day to decrease CO2 level, improve quality of sleep, and enhance functional level during the day. Signs of increasing CO2 level indicate need for more aggressive therapy.

8. Instruct asthmatic client in use of peak flow meter as appropriate.
Rationale: Peak flow level can drop before client exhibits any signs and symptoms of asthma after the “first time” the client is exposed to a trigger. Regular use of the peak flow meter may reduce the severity of the attack because of earlier intervention.

9. Provide information and encourage participation in support groups sponsored by the American Lung Association and public health department.
Rationale: These clients and their SOs may experience anxiety, depression, and other reactions as they deal with a chronic disease that has an impact on their desired lifestyle. Support groups may be desired or needed to provide assistance, emotional support, and respite care.

10. Refer for evaluation of home care if indicated. Provide a detailed plan of care and baseline physical assessment to home care nurse as needed on discharge from acute care.
Rationale: Provides for continuity of care. May help reduce frequency of hospitalization.

Nursing Diagnosis for Thrombophlebitis | Knowledge Deficit

Nursing diagnosis: deficient Knowledge [Learning Need] regarding condition, treatment program, self-care, and discharge needs related to lack of exposure or recall; misinterpretation of information; unfamiliarity with information resources

Possibly evidenced by

Request for information, statement of misconception

Inaccurate follow-through of instructions

Development of preventable complications

Desired Outcomes/Evaluation Criteria—Client Will

Knowledge: Disease Process

Verbalize understanding of disease process, treatment regimen, and limitations.

Participate in learning process.

Identify signs and symptoms requiring medical evaluation.

Knowledge: Treatment Regimen

Correctly perform therapeutic actions and explain reasons for actions.

Nursing care plan intervention with rationale:

1. Review pathophysiology of condition and signs and symptoms of possible complications, such as PE, chronic venous insufficiency, and venous stasis ulcers (postphlebitic syndrome).

Rationale: Provides a knowledge base from which client can make informed choices and understand and identify healthcare needs. A significant number of clients experience a recurrence of DVT. Note: Genetic blood testing may help identify inherited thrombotic disorders. Screening tests should be done when venous thrombosis occurs in those aged 45 years or younger; when a thrombus occurs at an unusual location such as in gastrointestinal tract, brain, or arm; and when there is an immediate family history of DVT.

2. Explain purpose of activity restrictions and need for balance between activity and rest.

Rationale: Rest reduces oxygen and nutrient needs of compromised tissues and decreases risk of fragmentation of thrombosis. Balancing rest with activity prevents exhaustion and further

impairment of cellular perfusion.

3. Establish appropriate exercise and activity program.

Rationale: Aids in developing collateral circulation, enhances venous return, and prevents recurrence.

4. Problem-solve solutions to predisposing factors that may be present, such as employment that requires prolonged standing or sitting, wearing restrictive clothing, use of oral contraceptives, obesity, prolonged immobility, and dehydration.

Rationale: Actively involves client in identifying and initiating lifestyle and behavior changes to promote health and prevent recurrence of condition or development of complications.

5. Recommend sitting with feet touching the floor, avoiding crossing of legs.

Rationale: Prevents excess pressure on the popliteal space.

6. Review purpose and demonstrate correct application and removal of antiembolic hose.

Rationale: Understanding may enhance cooperation with prescribed therapy and prevent improper or ineffective use.

7. Instruct in meticulous skin care of lower extremities, such as prevent or promptly treat breaks in skin and report development of ulcers or changes in skin color.

Rationale: Chronic venous congestion and postphlebitic syndrome may develop, especially in presence of severe vascular involvement and recurrent DVT, potentiating risk of stasis ulcers.

8. Discuss purpose and dosage of anticoagulant. Emphasize importance of taking drug as prescribed.

Rationale: Promotes client safety by reducing risk of inadequate therapeutic response and deleterious side effects.

9. Identify safety precautions, such as use of soft toothbrush, electric razor for shaving, gloves for gardening, avoiding sharp objects (including toothpicks), walking barefoot, engaging in rough sports and activities, or forceful blowing of nose.

Rationale: Reduces the risk of traumatic injury, which potentiates bleeding or clot formation.

10. Review client’s usual medications and foods when on oral anticoagulants, stress need to read ingredient labels of over-the-counter (OTC) drugs and herbal supplements, and discuss use with healthcare provider prior to starting new medications.

Rationale: Warfarin (Coumadin) interacts with many foods and drugs, either increasing or decreasing the anticoagulant effect. Salicylates and excess alcohol decrease prothrombin activity, whereas vitamin K (multivitamins, bananas, leafy green vegetables) increases prothrombin activity and can cause a higher or lower INR, possibly outside the therapeutic range. Barbiturates increase metabolism of coumarin drugs; antibiotics alter intestinal flora and may interfere with vitamin K synthesis.

Nursing Diagnosis for Cardiac Surgery | Knowledge Deficit

Nursing diagnosis: deficient Knowledge [Learning Need] regarding condition, postoperative care, self-care, and discharge needs related to lack of exposure or recall; information misinterpretation

Possibly evidenced by

Questions and requests for information

Verbalization of problem, statement of misconception

Inaccurate follow-through of instructions

Desired Outcomes/Evaluation Criteria—Client Will

Cardiac Disease Self-Management

Participate in learning process.

Assume responsibility for own learning.

Begin to ask questions and look for information.

Knowledge: Treatment Regimen

Verbalize understanding of condition, prognosis, and potential complications.

Describe reasons for therapeutic actions.

Nursing intervention with rationale:

1. Reinforce surgeon’s explanation of particular surgical procedure, providing diagram as appropriate.

Rationale: Provides individually specific information, creating knowledge base for subsequent learning regarding home management. Length of rehabilitation and prognosis are dependent on type of surgical procedure, preoperative physical condition, and duration and severity of any complications.

2. Discuss importance of reporting changes in memory or mentation.

Rationale: Cerebral dysfunction ranging from focal ischemic injury to encephalopathy has been associated with CPB and may present from 1 to several days after the procedure, thus affecting length of stay and mortality rates (McKhann et al, 2002, 2006).

3. Reinforce continuation of breathing exercises, incentive spirometry, and coughing with splinting incision.

Rationale: Promotes alveolar ventilation, reducing risk of lung congestion.

4. Discuss routine and prophylactic medications and OTC drug use. Stress importance of checking with physician before taking any drugs. Reinforce need for routine laboratory tests, outpatient education, and community resources when client with valve replacement will be taking warfarin (Coumadin).

Rationale: Depending on type of valve replacement (i.e., synthetic), lifelong anticoagulant therapy may be indicated. Potential for drug interactions must be considered before adding therapeutic agents to regimen. Note: Using herbal products, such as ginkgo, garlic, and vitamins, can alter coagulation and have an adverse effect when taken with anticoagulants.

5. Review prescribed cardiac rehabilitation or exercise program and progress to date. Assist client and significant other (SO) to set realistic goals.

Rationale: Individual capabilities and expectations depend on type of surgery, underlying cardiac function, and prior physical conditioning. Note: Obesity is a predictor of hospital readmission and may require additional interventions.

6. Encourage participation in home routines, such as self-care and cooking. Suggest alternating rest periods with activity, and light tasks with heavy tasks. Avoid heavy lifting and isometric and strenuous upper-body exercise.

Rationale: Prevents excessive fatigue and exhaustion. Scheduling rest periods and short naps several times a day enhances coping abilities, reduces nervousness (common in this phase),

and promotes healing. Note: Strenuous use of arms can place undue stress on sternotomy.

7. Problem-solve with client and SO ways to continue progressive activity program during temperature extremes and high wind or pollution days, such as walking predetermined distance within own house, in local indoor shopping mall, or on exercise track.

Rationale: Having a plan forestalls giving up exercise because of interferences such as weather.

8. Reinforce physician’s time limitations about lifting, driving, returning to work, resuming sexual activity, and exercising that involves upper extremities.

Rationale: These restrictions are present until after the first postoperative office visit for assessment of sternum healing.

9. Assist client and SO to develop strategies for dealing with changes during recovery period, such as shifting responsibilities to other family members, friends, or neighbors; acquiring temporary assistance for housekeeping; and investigating avenues for financial assistance.

Rationale: Planning for changes that may occur or be required promotes sense of control and accomplishment without loss of self-esteem.

10. Identify services and resources available after discharge. Provide telephone contact number or schedule follow-up calls as appropriate. Include referral names for home care

services, as indicated.

Rationale: Facilitates transition to home and provides for ongoing monitoring, continuation of prescribed therapies, and opportunity to discuss concerns and alleviate anxiety.

Nursing Diagnosis for Dysrhythmias | Knowledge Deficit

Nursing diagnosis: deficient Knowledge [Learning Need] regarding cause, treatment, self-care, and discharge needs related to lack of information, misunderstanding of medical condition or therapy needs; unfamiliarity with information resources; lack of recall.

Possibly evidenced by

Questions, statement of misconception

Failure to improve on previous regimen

Development of preventable complications

Desired Outcomes/Evaluation Criteria—Client Will

Knowledge: Disease Process

Verbalize understanding of condition, prognosis, and function of pacemaker (if used).

Relate signs of pacemaker failure.

Knowledge: Treatment Regimen

Verbalize understanding of therapeutic regimen.

List desired action and possible adverse side effects of medications.

Correctly perform necessary procedures and explain reasons for actions.

Nursing intervention with rationale:

1. Assess client and SO level of knowledge and ability and desire to learn.

Rationale: Necessary for creation of individual instruction plan. Reinforces expectation that this will be a “learning experience.” Verbalization identifies misunderstandings and allows for clarification.

2. Be alert to signs of avoidance, such as changing subject away from information being presented or extremes of behavior (withdrawal or euphoria).

Rationale: Natural defense mechanisms, such as anger or denial of significance of situation, can block learning, affecting client’s response and ability to assimilate information. Changing to

a less formal or structured style may be more effective until client and SO are ready to accept and deal with current situation.

3. Present information in varied learning formats, for example, programmed books, audiovisual tapes, question-andanswer sessions, and group activities.

Rationale: Multiple learning methods may enhance retention of material.

4. Provide information in written form for client and SO to take home.

Rationale: Follow-up reminders may enhance client’s understanding and cooperation with the desired regimen. Written instructions are a helpful resource when client is not in direct contact with healthcare team.

5. Reinforce explanations of risk factors, dietary and activity restrictions, medications, and symptoms requiring immediate medical attention.

Rationale: Provides opportunity for client to retain information and to assume control and participate in rehabilitation program.

6. Encourage identification and reduction of individual risk factors, such as smoking and alcohol consumption and obesity.

Rationale: These behaviors and chemicals have direct adverse effect on cardiovascular function and may impede recovery and increase risk for complications.

7. Explain and reinforce specific dysrhythmia problem and therapeutic measures to client and SO.

Rationale: Ongoing and updated information, such as whether the problem is resolving or may require long-term control measures, can decrease anxiety associated with the unknown and prepare client and SO to make necessary lifestyle adaptations. Educating the SO may be especially important if client is elderly, visually or hearing impaired, or unable or even unwilling to learn or follow instructions. Repeated explanations may be needed because anxiety and bulk of new information can block or limit learning.

8. Identify adverse effects and complications of specific dysrhythmias, such as fatigue, dependent edema, progressive changes in mentation, vertigo, and psychological manifestations.

Rationale: Dysrhythmias may decrease cardiac output, manifested by symptoms of developing cardiac failure and altered cerebral perfusion. Tachydysrhythmias may also be accompanied by debilitating anxiety and feelings of impending doom.

9. Instruct and document teaching regarding medications. Include the desired action, how and when to take the drug, what to do if a dose is forgotten (dosage and usage information), and expected side effects or possible adverse reactions or interactions with other prescribed and OTC drugs or substances (alcohol, tobacco, herbal remedies), as well as what and when to report to the healthcare provider.

Rationale: Information necessary for client to make informed choices and to manage medication regimen. Note: Use of herbal remedies in conjunction with drug regimen may result in adverse effects, for example, cardiac stimulation and impaired clotting, necessitating evaluation of product for safe use.

10. Encourage development of regular exercise routine, avoiding overexertion. Identify signs and symptoms requiring immediate cessation of activities, such as dizziness, lightheadedness, dyspnea, and chest pain.

Rationale: When dysrhythmias are properly managed, normal activity should not be affected. Exercise program is useful in improving overall cardiovascular well-being.

Nursing Diagnosis for Angina Pectoris | Knowledge Deficit

Nursing diagnosis: knowledge deficit regarding condition, treatment needs, self-care, and discharge needs related to lack of exposure; inaccurate information or misinterpretation of information; unfamiliarity with information resources

Possibly evidenced by

Questions, statement of concerns

Request for information

Inaccurate follow-through of instructions

Desired Outcomes/Evaluation Criteria—Client Will

Participate in learning process.

Assume responsibility for own learning, looking for information and asking questions.

Knowledge: Cardiac Disease Management

Verbalize understanding of condition, disease process, and potential complications.

Verbalize understanding of and participate in therapeutic regimen.

Initiate necessary lifestyle changes.

Nursing care plan intervention with rationale:

1. Discuss pathophysiology of condition. Stress need for preventing and managing anginal attacks.

Rationale: Clients with angina need to learn why it occurs and what they can do to control it. This is the focus of therapeutic management to reduce likelihood of MI and promote heart-healthy lifestyle.

2. Review significance of cholesterol levels and differentiate between LDL and HDL factors. Emphasize importance of periodic laboratory measurements and use of cholesterol- lowering drugs.

Rationale: Although the American Heart Association recommended LDL is 130 mg/dL, clients with two or more risk factors, including smoking, hypertension, diabetes mellitus, and positive family history, should keep LDL 100 mg/dL, and those with diagnosis of CAD need to keep LDL below 100 mg/dL. HDL below 35 to 45 is considered a risk factor; a level above 60 mg/dL is considered an advantage. Note: The National Cholesterol Education Program Guidelines now state that all adult high-risk clients with LDL of 100 mg/dL should be treated with drug therapy.

3. Encourage avoidance of factors or situations that may precipitate anginal episode, such as emotional stress, extensive or intense physical exertion, ingestion of large or heavy meal (especially close to bedtime), and exposure to extremes in environmental temperature.

Rationale: May reduce incidence or severity of ischemic episodes. Helps client manage symptoms.

4. Assist client or SO to identify sources of physical and emotional stress and discuss ways that they can be avoided.

Rationale: This is a crucial step in limiting or preventing anginal attacks.

5. Encourage client to follow prescribed reconditioning program; caution client to avoid exhaustion.

Rationale: Fear of triggering attacks may cause client to avoid participation in activity that has been prescribed to enhance recovery by increasing myocardial strength and forming collateral circulation. Cardiac rehabilitation programs provide a phased approach to increasing client’s activity and exercise tolerance.

6. Discuss impact of condition on desired lifestyle and activities, including work, driving, sexual activity, and hobbies. Provide information, privacy, or consultation, as indicated.

Rationale: Client may be reluctant to resume or continue usual activities because of fear of anginal attack or death. Client should take nitroglycerin prophylactically before any activity that is known to precipitate angina. Note: ED can be sign of CAD or diabetes in men. Use of Viagra, or similar drugs, is contraindicated with nitrates, which are usually used with angina.

7. Demonstrate how and encourage client to monitor own pulse and BP during and after activities, when appropriate, and to schedule and simplify activities, avoid strain, and take rest periods.

Rationale: Allows client to identify those activities that can be modified to avoid cardiac stress and stay below the anginal threshold.

8. Discuss steps to take when anginal attacks occur, such as cessation of activity, keeping “rescue” NTG on hand, administration of PRN medication, and use of relaxation techniques.

Rationale: Being prepared for an event takes away the fear that client will not know what to do if attack occurs.

9. Review prescribed medications for control and prevention of anginal attacks as previously presented:

Rationale:Angina is a complicated condition that often requires the use of many drugs to decrease myocardial workload, improve coronary circulation, and control the occurrence of attacks.

a). ASA and other antiplatelet agents

Rationale: May be given prophylactically on a daily basis to decrease platelet aggregation and improve coronary circulation. May prolong survival rate of clients with unstable angina.

b). Lipid-lowering agents: bile acid sequestrants, such as cholestyramine (Questran), colestipol (Colestid), and nicotinic acid (Niacin); fibrates, such as fenofibrate (Tricor) and gemfibrozil (Lopid); and HMG-CoA reductase inhibitors, such as lovastatin (Lipitor), fluvastatin (Lescol),

pravastatin (Pravachol), and simvastatin (Zocor)

Rationale: These drugs are considered first-line agents for lowering serum cholesterol levels. Note: Questran and Colestid may inhibit absorption of fat-soluble vitamins and some drugs,

such as Coumadin, Lanoxin, and Inderal. The HMG-CoA reductase inhibitors may cause photosensitivity. Most lipid-lowering agents are inhibited by grapefruit juice.

10. Stress importance of checking with physician before taking OTC drugs.

Rationale: OTC drugs may potentiate or negate effects of prescribed medications.

11. Discuss use of herbals such as ginseng, garlic, ginkgo, hawthorn, and bromelain, as indicated.

Rationale: Some herbals, such as ginkgo, ginseng, and bromelain can affect bleeding and clotting, especially when added to medications such as Plavix or Coumadin, which increase

bleeding. Others, such as hawthorn, can increase the effects of certain heart medications.

12. Review symptoms to be reported to physician, particularly an increase in frequency and duration of attacks and changes in response to medications.

Rationale: Knowledge of expectations can avoid undue concern for insignificant reasons or delay in treatment of important symptoms.

13. Discuss importance of follow-up appointments.

Rationale: Angina is a symptom of progressive CAD that should be monitored and may require occasional adjustment of treatment regimen.

Nursing Diagnosis for Heart Failure | Knowledge Deficit

Nursing diagnosis: Knowledge deficit [Learning Need] regarding condition, treatment regimen, self-care, and discharge needs related to lack of understanding, misconceptions about interrelatedness of cardiac function, disease, and failure.

Possibly evidenced by

Questions

Statements of concern, misconceptions

Recurrent, preventable episodes of HF

Desired Outcomes/Evaluation Criteria—Client Will

Knowledge: Cardiac Disease Management

Identify relationship of ongoing therapies (treatment program) to reduction of recurrent episodes and prevention of complications.

List signs and symptoms that require immediate intervention.

Identify own stress and risk factors and some techniques for handling them.

Initiate necessary lifestyle and behavioral changes.

Nursing care plan intervention with rationale:

1. Discuss normal heart function. Include information regarding client’s variance from normal function. Explain difference between heart attack and HF.

Rationale: Knowledge of disease process and expectations can facilitate client’s participation in management of HF, including prescribed treatment regimen (Tenenbaum, 2003).

2. Reinforce treatment rationale. Include SO and family members in teaching as appropriate, especially for complicated regimens such as management of technology, for example,

implantable cardioverter-defibrillator (ICD) or LVAD, dobutamine infusion home therapy when client does not respond to customary combination therapy or cannot be weaned.

Rationale: Client may believe it is acceptable to alter postdischarge regimen when feeling well and symptom-free or when feeling below par, which can increase the risk of exacerbation of symptoms. Understanding of regimen, medications, technology, and restrictions may augment cooperation with control of symptoms. Home IV therapy requires a significant commitment by caregivers to operate and troubleshoot infusion pump, change dressing for peripherally inserted central catheter (PICC) line, and monitor I&O and signs and symptoms of HF.

3. Encourage developing a regular home exercise program and provide guidelines for sexual activity.

Rationale: Promotes maintenance of muscle tone and organ function for overall sense of well-being. Changing sexual habits, for example, sex in morning when well rested, client on top,

inclusion of other physical expressions of affection, may be difficult, but provides opportunity for continuing satisfying sexual relationship.

4. Discuss importance of being as active as possible without becoming exhausted and need for rest between activities.

Rationale: Excessive physical activity or overexertion can further weaken the heart, exacerbating failure, and necessitates adjustment of exercise program.

5. Discuss importance of sodium limitation. Provide list of sodium content of common foods that are to be avoided or limited. Encourage reading of labels on food and drug packages.

Rationale: Dietary intake of sodium of more than 3 g/day can offset effect of diuretic. Most common source of sodium is table salt and obviously salty foods, although canned soups and vegetables, luncheon meats, and dairy products also may contain high levels of sodium.

6. Refer to dietitian for counseling specific to individual needs and dietary customs.

Rationale: Identifies dietary needs, especially in presence of obesity (major risk factor for developing HF), diabetes, or presence of nausea and vomiting and resulting wasting syndrome (cardiac cachexia). Eating six small meals and using liquid dietary supplements and vitamin supplements can limit inappropriate weight loss.

7. Review medications, purpose, and side effects. Provide both oral and written instructions.

Rationale: Understanding therapeutic needs and importance of prompt reporting of side effects can prevent occurrence of drugrelated complications. Anxiety may block comprehension of input or details, and client and SO may refer to written material at later date to refresh memory.

8. Recommend taking diuretic early in morning.

Rationale: Provides adequate time for drug effect before bedtime to prevent or limit interruption of sleep.

9. Instruct and receive return demonstration of ability to take and record daily pulse and BP and when to notify healthcare provider, for example, parameters above or below preset rate and changes in rhythm or regularity.

Rationale: Promotes self-monitoring of condition and drug effect. Early detection of changes allows for timely intervention and may prevent complications, such as digoxin toxicity.

10. Explain and discuss client’s role in control of risk factors, such as smoking and alcohol abuse, and precipitating or aggravating factors, such as high-salt diet, inactivity or overexertion, and exposure to extremes in temperature.

Rationale: Adds to body of knowledge and permits client to make informed decisions regarding control of condition and prevention of recurrence or complications. Smoking potentiates vasoconstriction; sodium intake promotes water retention and edema formation. Improper balance between activity and rest and exposure to temperature extremes may result in exhaustion, increased myocardial workload, and increased risk of respiratory infections. Alcohol can depress cardiac contractility. Limitation of alcohol use to social occasions or maximum of one drink per day may be tolerated unless cardiomyopathy is alcohol induced, which requires complete abstinence.

11. Review signs and symptoms that require immediate medical attention, such as rapid and significant weight gain, edema, shortness of breath, increased fatigue, cough, hemoptysis,

and fever.

Rationale:Self-monitoring increases client responsibility in health maintenance and aids in prevention of complications such as pulmonary edema, pneumonia. Weight gain of more than 3 lb in 1 week requires medical evaluation or adjustment of diuretic therapy. Note: Client should weigh self daily in morning without clothing, after voiding, and before eating.

12. Provide opportunities for client and SO to ask questions, discuss concerns, and make necessary lifestyle changes.

Rationale: Chronicity and recurrent, debilitating nature of HF often exhausts coping abilities and supportive capacity of both client and SO, leading to depression.

13. Address caregiver’s concerns and needs. Refer for support, assistance, and resources, as indicated.

Rationale: Caregiver burden can exhaust SO’s coping capabilities and health, especially when client has advanced HF, has a ventricular assist device, or is awaiting heart transplantation.

14. Discuss general health risks, such as infection, and recommend avoidance of crowds and individuals with respiratory infections and obtaining yearly influenza immunization and

one-time pneumonia immunization.

Rationale: This population is at increased risk for infection because of circulatory compromise.

15. Stress importance of reporting signs and symptoms of digoxin toxicity: development of gastrointestinal and visual disturbances, changes in pulse rate and rhythm, and worsening

of HF.

Rationale: Early recognition of developing complications and involvement of healthcare provider may prevent toxicity and hospitalization.

16. Identify community resources or support groups and visiting home health nurse, as indicated.

Rationale: May need additional assistance with self-monitoring and home management, especially when HF is progressive.

17 Discuss importance of advance directives and of communicating plan and wishes to family and primary care providers.

Rationale: Up to 50% of all deaths from HF are sudden, with many occurring at home, possibly without significant worsening of symptoms. If client chooses to refuse life-support measures, an alternative contact person (rather than 911) needs to be designated, should cardiac arrest occur.

Nursing Diagnosis: Knowledge Deficit | Hypertension

Nursing diagnosis: Knowledge deficit [Learning Need] regarding condition, treatment plan, self-care, and discharge needs related to lack of knowledge and recall, information misinterpretation, cognitive limitation, and denial of diagnosis

Possibly evidenced by

Verbalization of the problem

Request for information

Statement of misconception

Inaccurate follow-through of instructions, inadequate performance of procedures

Inappropriate or exaggerated behaviors, such as hostility, agitation, or apathy

Desired Outcomes/Evaluation Criteria—Client Will

Knowledge: Hypertension Management

Verbalize understanding of disease process and treatment regimen.

Identify drug side effects and possible complications that necessitate medical attention.

Maintain BP within individually acceptable parameters.

Describe reasons for therapeutic actions and treatment regimen.

Nursing care plan intervention with rationale

1. Assist client in identifying modifiable risk factors, such as obesity; diet high in sodium, saturated fats, and cholesterol; sedentary lifestyle; smoking; alcohol intake of more than

2 ounces per day on a regular basis; and a stressful lifestyle.

Rationale: These risk factors contribute to hypertension and cardiovascular and renal disease.

2. Problem-solve with client to identify ways in which appropriate lifestyle changes can be made to reduce modifiable risk factors.

Rationale: Changing “comfortable or usual” behavior patterns can be very difficult and stressful. Support, guidance, and empathy can enhance client’s success in accomplishing his or her health goals.

3. Discuss importance of eliminating smoking, and assist client in formulating a plan to quit smoking. Refer to smoking cessation program or healthcare provider for helpful medications.

Rationale: Nicotine increases catecholamine discharge, resulting in increased heart rate, BP, vasoconstriction, and myocardial workload, and reduces tissue oxygenation.

4. Reinforce the importance of adhering to treatment regimen and keeping follow-up appointments.

Rationale: Lack of engagement in the treatment plan is a common reason for failure of antihypertensive therapy. Therefore, ongoing evaluation for client participation is critical to successful treatment. When client understands causative factors and consequences of inadequate intervention and is motivated to achieve health, the client typically participates in

treatment interventions.

5. Instruct and demonstrate BP self-monitoring technique. Evaluate client’s hearing, visual acuity, manual dexterity, and coordination.

Rationale: Monitoring BP at home is reassuring to client because it provides visual feedback to determine treatment outcomes and helps promote early detection of deleterious changes.

6. Help client develop a simple, convenient schedule for taking medications.

Rationale: Individualizing schedule to fit client’s personal habits may make it easier to get in the habit of including antihypertensives in healthcare management activities.

7. Explain prescribed medications along with their rationale, dosage, expected and adverse side effects, and particular traits, such as the following:

Rationale: Adequate information and understanding about side effects can enhance client’s commitment to the treatment plan. For instance, mood changes, initial weight gain, and dry mouth are common and often subside with time.

7.1. Diuretics: Take daily or larger dose in the early morning. Weigh self on a regular schedule and record. Avoid or limit alcohol intake.

Rationale: Scheduling doses early in the day minimizes nighttime urination. Primary indicator of effectiveness of diuretic therapy. The combined vasodilating effect of alcohol and the volumedepleting effect of a diuretic greatly increase the risk of orthostatic hypotension.

a. Notify physician if unable to tolerate food or fluid.

Rationale: Dehydration can develop rapidly if intake is poor and client continues to take a diuretic.

7.2. Antihypertensives: Take prescribed dose on a regular schedule; avoid skipping, altering, or making up doses; and do not discontinue without notifying the healthcare provider. Review potential side effects and drug interactions, and discuss need for informing healthcare provider about onset of adverse effects such as ED.

Rationale: Because clients often cannot feel the difference the medication is making in BP, it is critical that there be understanding about the medication’s actions and side effects. For example, abruptly discontinuing a drug may cause rebound hypertension leading to severe complications, or medication may need to be altered to reduce adverse effects. Note: Many drugs used to treat hypertension have been linked to ED. Drugs may need to be changed or dose adjusted.

a. Rise slowly from a lying to standing position, sitting for a few minutes before standing. Sleep with the head slightly elevated. Suggest frequent position changes and leg exercises when lying down.

Rationale: Measures reduce potential for orthostatic hypotension associated with the use of vasodilators and diuretics.

b. Recommend avoiding hot baths, steam rooms, and saunas, especially with concomitant use of alcoholic beverages.

Rationale: Prevents vasodilation with potential for dangerous side effects of syncope and hypotension.

c. Instruct client to consult healthcare provider before taking other prescription or over-the-counter (OTC) medications.

Rationale: Any drug that contains a sympathetic nervous stimulant may increase BP or counteract effects of antihypertensive medications.

8. As indicated, instruct client about increasing intake of foods and fluids high in potassium, such as oranges, bananas, figs, dates, tomatoes, potatoes, raisins, apricots, Gatorade, and fruit juices, and foods and fluids high in calcium, such as low-fat milk, yogurt, or calcium supplements.

Rationale: Some diuretics can deplete potassium levels. Dietary potassium is desirable means of correcting deficits and may be more palatable to the client than drug supplements. Correcting mineral deficiencies can also affect BP.

9. Review the signs and symptoms that require the client to notify the healthcare provider, such as headache present on awakening that does not abate; sudden and continued increase of BP; chest pain; shortness of breath; irregular or increased pulse rate; significant weight gain (2 lb/day or 5 lb/wk); peripheral or abdominal swelling; visual disturbances; frequent, uncontrollable nosebleeds; depression or emotional lability; severe dizziness or episodes of fainting; muscle weakness or cramping; nausea or vomiting; or excessive thirst.

Rationale: Early detection and reporting of developing complications, decreased effectiveness of drug regimen, or adverse reactions allows for timely intervention.

10. Explain rationale for prescribed dietary regimen—usually a diet low in sodium, saturated fat, and cholesterol.

Rationale: Excess saturated fats, cholesterol, sodium, alcohol, and calories have been defined as nutritional risks in hypertension. A diet low in fat and high in polyunsaturated fat reduces

BP, possibly through prostaglandin balance in both normotensive and hypertensive people.

11. Help client identify sources of sodium intake, such as table salt, salty snacks, processed meats and cheeses, sauerkraut, sauces, canned soups and vegetables, baking soda, baking powder, and monosodium glutamate. Stress the importance of reading ingredient labels of foods and OTC drugs.

Rationale: A moderately low-salt diet may be sufficient to control mild hypertension or reduce or eliminate the need for drug therapy needed to control BP.

12. Encourage foods rich in essential fatty acids, such as salmon, cod, mackerel, and tuna.

Rationale: Omega-3 fatty acids in fish tend to relax artery walls, reducing blood pressure. They also make blood thinner and less likely to clot.

13. Encourage client to establish a regular exercise program, incorporating aerobic exercise within client’s capabilities. Stress the importance of avoiding isometric activity.

Rationale: Besides helping to lower BP, aerobic activity aids in toning the cardiovascular system. Isometric exercise can increase serum catecholamine levels, further elevating BP.

14. Demonstrate application of ice pack to the back of the neck and pressure over the distal third of nose, and recommend that client lean head forward if nosebleed occurs.

Rationale: Nasal capillaries may rupture as a result of excessive vascular pressure. Cold temperature and pressure constrict capillaries to slow or halt bleeding. Leaning forward reduces the amount of blood that is swallowed.

15. Provide information regarding community resources, and support client in making lifestyle changes. Initiate referrals, as indicated.

Rationale: Community resources, such as the American Heart Association, “coronary clubs,” stop smoking clinics, alcohol or drug rehabilitation, weight loss programs, stress management classes, and counseling services may be helpful in client’s efforts to initiate and maintain lifestyle changes.