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condition worsens)
Narrowed focus
Desired Outcomes
Nursing Interventions
Rationale
Pain and decreased cardiac output may
stimulate the sympathetic nervous system
to release excessive amounts of
norepinephrine, which increases platelet
of pain.
unstable angina.
Nursing Interventions
Rationale
parasympathetic nervous system, causing
a variety of vague sensations that patient
may not identify as related to anginal
episode.
side).
anginal episodes.
breath.
myocardial workload.
Nursing Interventions
Provide supplemental oxygen as indicated.
Rationale
Increases oxygen available for myocardial
uptake and reversal of ischemia.
spray.
(Inderal)
severe conditions.
Nursing Interventions
Rationale
vessels in response to nitrates.
Potent narcotic analgesic may be used in
acute onset because of its several
beneficial effects, e.g., causes peripheral
vasodilation and reduces myocardial
workload; has a sedative effect to produce
Desired Outcomes
Nursing Interventions
Maintain bed or chair rest in position of
comfort during acute episodes.
Rationale
Decreases oxygen demand therefore
reducing myocardial workload and risk of
decompensation.
Tachycardia may be present because of
pain, anxiety, hypoxemia, and reduced
cardiac output. Changes may also occur in
workload.
Nursing Interventions
Rationale
stimulation, reducing heart rate
indicated.
failure.
indicated.
Nursing Interventions
Rationale
contractility, and cardiac work can be
measured noninvasively through various
means, including thoracic electrical
bioimpedance (TEB) technique. Useful in
IV heparin
Nursing Interventions
Rationale
high-risk unstable angina. Note: Use of
low-molecular-weight heparin is increasing
because of its more efficacious and
predictable effect with fewer adverse
effects (less risk of bleeding) and longer
half-life. It also does not require
anticoagulation monitoring.
CABG, if indicated.
Nursing Interventions
Rationale
cardiac output reflects development of
condition warrants.
May be related to
Possibly evidenced by
Changes in BP (hypotension/hypertension)
Chest pain
Desired Outcomes
Nursing Interventions
Rationale
telemetry is available.
Nursing Interventions
Rationale
(AF) are common dysrhythmias associated
with HF, although others may also
occur. Note: Intractable ventricular
dysrhythmias unresponsive to medication
suggest ventricular aneurysm.
S1 and S2 may be weak because of
diminished pumping action. Gallop
Monitor BP.
Nursing Interventions
Rationale
to circulation when patient is recumbent.
indicated.
formation.
pallor of extremity.
thrombophlebitis.
Incidence of toxicity is high (20%)
Nursing Interventions
Rationale
indicated.
Angiotensin II receptor
Nursing Interventions
Rationale
and angiotensin II synthesis.
Increases force of myocardial contraction
when diminished contractility is the cause
of HF, and slows heart rate by decreasing
Digoxin (Lanoxin)
Beta-adrenergic receptor
Morphine sulfate.
(Coumadin).
Nursing Interventions
Rationale
dysrhythmias, and history of previous
thrombotic episodes.
Because of existing elevated left
Nursing Interventions
Rationale
studies.
therapy.
May be necessary to correct
Cardiomyoplasty.
Transmyocardial revascularization.
Nursing Interventions
Rationale
failing heart in the critically ill patient with
potentially reversible HF. A batterypowered ventricular assist device (VAD)
may also be used, positioned between the
cardiac apex and the descending thoracic
indicated.
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Auscultate breath sounds, noting crackles,
wheezes.
Rationale
Reveals presence of pulmonary congestion
and collection of secretions, indicating
need for further intervention.
deep breathing.
delivery.
pillows.
Place patient in Fowlers position and give
supplemental oxygen.
Nursing Interventions
Rationale
Hypoxemia can be severe during
pulmonary edema. Compensatory changes
are usually present in chronic HF. Note: In
indicated.
Bronchodilators: aminophylline