Renelle Anne S.

Villena
BSN 4B SHC.

Pt. Edwin Endaya Diagnosis: SupraVentricular Tachycardia t/c AMI

Subjective: Diagnosis Planning Intervention Rationale Evaluation
“Naghihina ako, Activity intolerance After 2 hrs of > Record/ monitor >To serve as
parang lagi akong r/t decreased nursing intervention, HR, rhythm, & BP baseline data &
inaantok at mabagal cardiac output & the pt will changes. determine pt’s
kumilos.” As cardiac depressant demonstrate response may
verbalized by pt. effects of certain measurable/ indicate myocardial
drugs as evidenced progressive increase oxygen deprivation
Objective: by alteration in HR & in tolerance for that may require
>w/ oxygen via BP, changes in skin activity w/ heart rate decrease in activity.
nasal cannula moisture & dev’t of rhythm & BP w/in > Assess client daily
regulated @ 4-5 dysrhythmias. pt’s normal limits & for appropriateness > Inappropriate
lpm. skin is warm and dry of activity and bed prolonged bed rest
>alterations in HR & with activity rest orders. orders may
BP rate. contribute to activity
>malaise, fatigue, intolerance.
shows generalized >promote bed/chair
weakness. rest. Provide >Reduces
>lethargy nonstress myocardial
>irregular HR; diversional activities workload.
skipped beats
>w/ slight dizzy > Allowing client to >Increasing activity
spells assist with helps to maintain
>loss of muscle positioning, muscle strength,
tone/ strength. transferring, and tone, and
>skin is cool & self-care as possible. endurance. Allowing
diaphoresis is Progress from sitting the client to
shown. in bed to dangling, participate
V/S shows as to chair sitting, to decreases the
follows: standing. perception of the
T-37 c client as incapable.
P-74 bpm
R-28 bpm >Reduce the risk of
BP-120/90 mmhg orthostatic
>Ensure hypotension. Also
that clients change avoid fluid shifting.
position slowly.
Consider using a
chair-bed or
positioning in
fowler’s
>Activity
intolerance may
>Observe and lead to
document skin pressure ulcers.
integrity several
times a day.

>Impaired mobility
> Assess for
is associated with
constipation.
increased risk of
bowel dysfunction,
including
constipation.

>positive
>Provide emotional reinforcement boost
support and them to participate.
encouragement to
client to gradually
increase activity.
Pt. Edwin Endaya Diagnosis: SupraVentricular Tachycardia t/c AMI
Subjective: Diagnosis Planning Intervention Rationale Evaluation
“Nahihirapan Impaired gas After 3-4 hrs of >auscultate breath >may indicate
pakong huminga exchange related to nursing intervention, sounds, Assess pulmonary edema
pag naka-higa kaya fluid volume excess the client will color, respiratory secondary to cardiac
lagi akong naka (pulmonary edema) demonstrate rate and depth, decompensation
upo.” As verbalized as evidenced by optimal gas effort, rythm
by pt pitting edema, exchange, maintain
coughing up blood, fluid balance as
Reports of nocturia shortness of evidenced by >suggest fluid
breathing, & normal BP, non- volume excess
Objectives: nocturia. labored, be free of >note development
>shortness of edema & clear of edema, by
breathing. breathing also pressing skin. >decreased cardiac
>w/ Oxygen via verbalize comfort. output results
nasal cannula >measure intake & sodium water
regulated @ 4-5 lpm output, noting retention & reduced
>orthopnea decrease In output. urine output
>Excessive
sweating and pale > to facilitate
skin > Position client in optimum breathing
>w/ productive sitting or semi patterns
cough producing fowler’s
sticky blood >to facilitate better
streaked sputum > teach & lung expansion
scanty in amount. encourage client to
>pitting edema , cough and deep
swelling of the legs. breathing. >less work &
>crackles heard activity decrease
upon auscultation >provide adequate oxygen supply
on both lung. rest periods demand.
>increased RR rate
with labored >to release the
breathing > suction if needed secretions & prevent
>repo aspiration.

V/S shows as >to decrease

follows: >monitor fluid viscosity of
T-37 c intake but secretions if
P-82 bpm encourage to sip indicated
R-33 bpm water if indicated
BP-130/100 mmhg

> Necessary to
>administer correct fluid
diuretics (lasix) as overload & decrease
ordered. pulmonary edema.

> nebulization helps

to decrease
viscosity &loosen
>administer the secretion.
nebulization
(atrovent) as
ordered.
Pt. Edwin Endaya Diagnosis: SupraVentricular Tachycardia t/c AMI
Subjective: Diagnosis Planning Intervention Rationale Evaluation
“ di ko alam kung Anxiety related to After 1-2 hrs of >identify pt’s >ongoing anxiety
gagaling pa ako, unknown outcome nursing intervention, perception of threat, related to concerns
natatakot din ako sa of health state as the client will encourage their about impact of
mangyayari.” As evidenced by fearful demonstrate verbalization of heart may be
verbalized by pt. attitude, elevated decrease in anxiety feelings and do not present and may be
BP & HR, facial by recognize deny feelings of manifested by
Objective: tension & concern feelings, anger, grief, symptoms of
>increased facial about his health in verbalization of sadness, fear depression
tension the future. relief of anxiety and
>shows fearful be able to > Assist patient to >bedside and
attitude Discuss/demonstrat reduce present level presence with the pt
>feelings of e effective coping of anxiety by: gives a feeling of
inadequacy mechanisms for  Provide comfort support and honest
>focus on self, dealing with anxiety. and maintain a explanations
expresses of confident manner alleviate anxiety
concern about the w/o false
future event. reassurance.
>elevated BP  Stay with
>elevated HR person..
>dry mouth,  Speak slowly and
frequent urination, calmly
excessive sweating.
>accept but do not
reinforce use of >denial can
denial, avoid postpone w/ dealing
confrontation w/ the reality of the
current situation
>orient pt/ SO to
routine procedures >it can decrease
& experienced anxiety for pt & SO
activities. Promote
participation when
possible. Answer all
question with honest
explanations

>Provide rest >conserves energy

periods, quiet & enhances coping
environment
> promotes
> administer relaxation/ rest &
anxiolytics(diazepam reduces feelings of
) as ordered anxiety.