NURSING CARE PLAN PROBLEM: NURSING DIAGNOSIS: Activity Intolerance r/t cardiac dysfunction, imbalance in oxygen supply and

consumption as evidenced by shortness of breath upon exertion. CAUSE ANALYSIS: The underlying mechanism of a heart attack is the destruction of heart muscle cells due to alack of oxygen. If these cells are not supplied with sufficient oxygen by the coronary arteries to meet their metabolic demands,they die by aprocess calledinfarction. The decrease in blood supply may bring about necrosis of the heart muscle which would make it weaker as a pump. As a result, the pumping mechanism of the heart will be ineffective thus giving the individual an insufficient supply of blood, bringing about an in efficient supply of oxygen to the tissues thus leading to easyfatigability uponsimple exertions. If the condition becomes severe, the patient may have inability in performing activitiesand show changesin vital signs uponperformance of activities. Also, there could be changes in the ECG showing signs of ischemia. CUES OBJECTIVE NURSING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE:

STO; After 4 hours of NI, the patient will use identified techniques to increase activity tolerance.

INDEPENDENT: 1. Establish rapport 2. Assess patients condition 3. Monitor VS 4. Identify causative factors leading to intolerance of activity 5. Encourage patient to assist with planning activities, with rest periods as necessary 6. Instruct patient in energy conservation techniques 7. Assist with active or passive ROM exercises 8. Assist patient with ambulation, as ordered, with progressive increases as patients tolerance permits 9. Adjust activities according to patients tolerance 10. Plan care with rest periods between activities 11. Provide positive atmosphere, while acknowledging difficulty of the situation for the patient 12. Assist patient with activities and monitor use of assistive devices 13. Promote comfort measures and provide for relief of pain 14. Provide referral to other disciplines as indicated.

STO: 1. to gain trust and cooperation 2. to determine signs and symptoms 3. changes in VSassist withmoni toringphysiologicresponses to increase in activity 4. .alleviation of factors that are known to createintolerance ca nassist withdevelopment of an activity levelprogram 5. to help give the patient a feeling of self-worth and wellbeing 6. to decrease energy expenditure and fatigue 7. to maintain joint mobility and muscle tone 8. to graduallyincrease the body to compensate for the increase in overload 9. to prevent overexertion 10. to reduce fatigue 11. helps to minimize frustration, re-channel activities 12. to protect client from injury 13. to enhance ability to participate in activities 14. to developindividuallyapprop riate After 4 hours of NI, the patient shall have use notified techniques to increase activity tolerance.

LTO:

OBJECTIVE: the patient manifested: - need for assistance upon movement - limited range of motionwith oxygen hooked via nasal cannula regulated at2 L/m The patient manifest: - tachypnea and increased blood pressure upon performance of activities - pallor - cyanosis - ischemic ECG changes LTO; After 4 days of NI, the patient will be able to increase andachieve desiredactivity leve l,progressively, withno intolera ncesymptoms noted,such as res piratorycompromise.

After 4 days of nursing intervention, the patient shall have increased and achieved desired activity level, progressively, with no intolerance symptoms noted, such as respiratory compromise.