Problem #1: risk for decreased Cardiac Output related to altered electrical conduction as evidenced by HR of 190 General Goal:

Outcome: Patient maintains adequate Cardiac Output related during shift Nursing Intervention: Response to Intervention: Rationales: 1. Provide calm and quiet environment. 1. Calm environment was provided 1. Reduces stimulation and 2. Demonstrate and encourage use of during shift. release of stress-related stress management behaviors such as 2. Stress management behaviors such catecholamines, which can cause relaxation techniques; guided imagery; as relaxation techniques; guided or aggravate dysrhythmias and and slow, deep breathing. imagery; and slow, deep breathing vasoconstriction, increasing 3. Auscultate heart sounds, noting rate, was not done during shift. myocardial workload. rhythm, presence of 3 Auscultation of heart sounds were 2. Reduces stimulation and extra heartbeats, and dropped beats during shift with no extra heartbeats, release of stress-related 4. Monitor vital signs. Assess and dropped beats noticed. catecholamines, which can cause adequacy of cardiac output and 4. .Vital signs were monitored or aggravate dysrhythmias and tissue perfusion, noting significant throughout shift vasoconstriction, increasing variations in BP, pulse myocardial workload. rate equality, respirations, changes in 3. Specific dysrhythmias are more skin color and temperature, clearly detected audibly than by level of consciousness and sensorium, palpation. Hearing extra and urine output during episodes of heartbeats or dropped beats helps dysrhythmias. identify dysrhythmias in the unmonitored client. 4. Although not all dysrhythmias are life-threatening, immediate treatment may be required to terminate dysrhythmia in the presence of alterations in cardiac output and tissue perfusion

Problem#2: Risk for falls related impaired physical mobility. General Goal: Patient will not sustain a fall during this shift. Outcome: Nursing Intervention: Response to Interventions: 1. Encourage use of mobility assistive devices when ambulating and 1. Patient did not transfer during transferring. shift. 2. Patient did not display any fall 2.) Monitor BP for signs of risks related to medications. Polypharmacy during shift BP108/67, RR 17, A&O x4 3. Place items used by the patient 3. 3Tray table, call light, phone and within easy reach, such as call light, personal possessions were urinal, water, telephone kept within reach during shift. 4. ) Encourage the patient to wear 4. Patient refused to wear non slip shoes or slippers with nonskid socks socks during shift. when ambulating

Rationales: 1. Improper use and maintenance of mobility aids such as canes, walkers, and wheelchairs increases the person's risk for falls. 2. Drugs that affect blood pressure and level of consciousness are associated with the highest fall risk. 3. Stretching to get items from bedside tables that are out of reach can disrupt the patient's balance and contribute to falls. 4. ) Nonskid footwear provides sure footing for the patient with diminished foot and toe lift when walking

Problem #3: Situational Low Self-Esteem related to hospitalization as evidenced by reports of feelings of helplessness and uselessness General Goal: ): Patient describes successes in current situations Outcome: Nursing Interventions: Response to Interventions: Rationales: 1. Spend time with the patient, set aside sufficient time so that the 1. Patient expressed feelings about 1. The patient needs time to encounter is unhurried. Provide his situation, fears, and anxieties of express concerns. Spending time environment conducive to the the rehabilitation process during with the patient expresses the expression of feelings shift. nurse's interest in and acceptance 2. ) Use active listening and open2. Patient was able to express of the patient's feelings. ended questions himself about how his frustrations 2. These communication 3. Convey a sense of respect for the with his disability and frustration techniques allow the patient to patient's abilities and strengths in with hospital environment during express concerns, fears, and ideas addition to recognizing problems and shift. without interruption concerns. 3. Acknowledged and encouraged the 3. Assistance with problem 4. Encourage patient to make patients ability to perform selfsolving and reality testing is best decisions about care and to perform hygiene and recognized his sense of provided within the context of a their own self-care. frustration during shift. trusting relationship. 4. Patient performed some self-care, 4. Each success will reinforce patient took part in making decisions positive self-esteem about taking meds and what hygiene he wanted.

Problem #4: Anxiety related to Health care environment General Goal: Patient uses effective coping mechanisms Outcome: Nursing Interventions: 1. Acknowledge awareness of the patient's anxiety 2. Reassure the patient that he is safe. Stay with the patient if this appears necessary. 3. Maintain a calm manner while interacting with the patient 4. Use simple language and brief statements when instructing the patient about self-care measures or about diagnostic and surgical procedures Response to Interventions: 1. Verbalized and acknowledged patients anxiety about pain and over stimulation of hospital environment. 2. Reassured patient whileinteracting with patient during shift. 3. Used calm soft tone when communicating with patient during shift 4. Used simple non jargon age appropriate language when communicating with patient during shift Rationales: Response to Intervention: 1. Because a cause for anxiety cannot always be identified, the patient may feel as though the feelings being experienced are counterfeit. Acknowledgment of the patient's feelings validates the feelings and communicates acceptance of those feelings. 2. The presence of a trusted person may help the person feel less threatened. Anxiety may escalate to a panic level if the patient feels threatened and unable to control environmental stimuli. 3. The health care provider can transmit his or her own anxiety to the hypersensitive patient. The patient's feeling of stability increases in a calm and nonthreatening atmosphere. 4. ) When experiencing moderate

to severe anxiety, patients may be unable to comprehend anything more than simple, clear, and brief instructions