CASE #2

Mr. Jackson is a 56-year old married man with 3 teenage children. he has a 20-year history of hypertension, ranging from SBP 130 to 160mmHg, and a
10-year history of uncontrolled diabetes mellitus, ranging from CBG 160-210mg/dL. He has been continuously smoking 15 sticks per day for the past 16 years
and his diet include high salt and high fat foods.
You are assigned to him on the second day of ICU admission post resuscitation. His mental status declares him to open his eyes to pain, uses
incomprehensible sounds since he is intubated, and withdrawn his hands when pain is inflicted. He has an indwelling catheter, and a central vascular access
on his left jugular vein. His vital signs are 94/68mmHg, 94bpm, 18cpm, 100% Oxygen saturation and mechanical ventilator and afebrile. IV drips include
Dopamine 200mg/5ml in NSS running at 2mcg/kg/min and Dobutamine 250mg/5ml in D5W 250ml running at 3mcg/kg/min.
Mechanical ventilator was set on the following settings: AC mode, FIO2 50%, PEEP 5, TV 10, RR 16.
Diagnostic laboratories include Serum Na, K, BUN, Crea, Urinalysis, Cardiac Enzymes and Lipid profile. Radiologic tests include Chest X-ray which showed
pulmonary congestion on the left lower lobe of the lung, 2D-Echo showing decreased cardiac output and 12-lead ECG showing ST elevation.

NURSING DIAGNOSIS GOAL INTERVENTIONS EXPECTED OUTCOME

(List 5 unique to the given Nursing Dx)

Actual Short Term 1. Initially assess, document, and report • Reports beginning relief of chest
to the physician the following: discomfort and symptoms.
Ineffective cardiac tissue perfusion After 2-3 hours of nursing intervention,
related to reduced coronary blood flow patient will relief of chest pain or a. The patient’s description of chest • Appears comfortable and is free of
discomfort. discomfort, including location, intensity, pain and other signs or symptoms.
radiation, duration, and factors that
affect it. Other symptoms such as • Respiratory rate, cardiac rate, and
nausea, diaphoresis, or complaints of blood pressure return to
unusual fatigue. prediscomfort level.

b. The effect of coronary ischemia on • Skin warm and dry.

perfusion to the heart (eg, change in
blood pressure, heart rhythm), to the • Adequate cardiac output as
brain (eg, changes in LOC), to the evidenced by:
kidneys (eg, decrease in urine output), Stable/improving ECG
and to the Heart rate and rhythm
skin (eg, color, temperature). Blood pressure
Mentation
 Urine output
2. Obtain a 12-lead ECG recording Serum BUN and creatinine
during symptomatic events, as Skin color and temperature
prescribed, to assess for ongoing
ischemia. • No adverse effects from medications.

3. Administer oxygen as prescribed.

4. Administer medication therapy as

prescribed and evaluate the patient’s
response continuously.

5. Ensure physical rest: backrest

elevated to promote comfort; diet as
tolerated; use of bedside commode;
use of stool softener to prevent
straining at stool. Provide a restful
environment, and allay fears and anxiety
by being calm and supportive.
Individualize visitation, based on patient
response.
Risk/Potential Short term 1. Initially, every 4 hours, and with • Blood pressure within the patient’s
chest discomfort, assess, document, normal range.
Risk for ineffective peripheral tissue After 2-3 hours of nursing intervention, and report to the physician the
perfusion related to decreased cardiac patient will maintain or attain of following: • Ideally, normal sinus rhythm
output adequate tissue perfusion. a. Hypotension without dysrhythmia is maintained, or
b. Tachycardia and other dysrhythmia patient’s baseline rhythm is
c. Activity intolerance maintained between 60 and 100 bpm
d. Mentation changes (use family without further dysrhythmia.
input)
e. Reduced urine output (less than • Prescribed activity is well tolerated.
30 mL/h)
f. Cool, moist, cyanotic extremities, • Remains alert and oriented and
decreased peripheral pulses, prolonged without cognitive or behavioral
capillary refill change.

2. Record intake and output. If patient is • Appears comfortable.

acutely ill, measure hourly urine output
and note decreases in output. • Urine output greater than 30 mL/h.

3. Closely monitor fluid intake including • Extremities warm and dry with
IV lines. Maintain fluid restriction if normal color.
ordered.
 4. Closely monitor for symptoms of
heart failure and decreased cardiac
output, including diminished quality of
peripheral pulses, cold and clammy skin
and extremities, increased respiratory
rate, presence of paroxysmal nocturnal
dyspnea or orthopnea, increased heart
rate, neck vein distention, decreased
level of consciousness, and presence of
edema.

5. Monitor laboratory tests such as

complete blood count, sodium level, and
serum creatinine.
Psycho-social Long Term 1. Assess, document, and report to the • Reports less anxiety.
physician the patient’s and family’s
Anxiety related to cardiac event After 2-3 days of nursing intervention, level of anxiety and coping mechanisms. • Patient and family discuss their
patient will reduce the anxiety. anxieties and fears about illness and
2. Assess the need for spiritual death.
counseling and refer as appropriate.
• Patient and family appear less
3. Assess the need for social service anxious.
referral.
• Appears restful, respiratory rate less
4. Recognize awareness of the patient’s than 16 breaths/min, heart rate less
anxiety. than 100 bpm without ectopic beats,
blood pressure within patient’s
5. Familiarize patient with the normal limits, skin warm and dry.
environment and new experiences or
people as needed. • Participates actively in a progressive
rehabilitation program.

• Practices stress reduction

techniques.