Nurse's Pocket Guide

decreased CARDIAC OUTPUT
• Review “danger” signs requiring immediate physician notification
(e.g., unrelieved or increased chest pain, functional
decline, dyspnea, edema), which may indicate deteriorating
cardiac function, heart failure.
• Encourage changing positions slowly, dangling legs before
standing to reduce risk for orthostatic hypotension.
• Give information about positive signs of improvement, such
as decreased edema, improved vital signs/circulation, to provide
encouragement.
• Teach home monitoring of weight, pulse, and/or blood pressure,
as appropriate, to detect change and allow for timely
intervention.
• Arrange time with dietician to determine/adjust individually
appropriate diet plan.
• Promote visits from family/SO(s) who provide positive social
interaction.
• Encourage relaxing environment, using relaxation techniques,
massage therapy, soothing music, quiet activities.
• Instruct in stress management techniques, as indicated,
including appropriate exercise program.
• Identify resources for weight reduction, cessation of smoking,
and so forth, to provide support for change.
• Refer to NDs Activity Intolerance; deficient Diversional Activity;
ineffective Coping, compromised family Coping; Sexual
Dysfunction; acute or chronic Pain; imbalanced Nutrition;
deficient or excess Fluid Volume, as indicated.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Baseline and subsequent findings and individual hemodynamic
parameters, heart and breath sounds, ECG pattern,
presence/strength of peripheral pulses, skin/tissue status,
renal output, and mentation.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s responses to interventions/teaching and actions performed.
• Status and disposition at discharge.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
150 Cultural Collaborative Community/Home Care