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Cardiac Care Plan Marking Guide

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Diploma of Nursing
HLTEN505C: Contribute to the complex care of clients

Assessment 1 of 5
Cardiac care plan marking guide
Instructions to Students

Students completing this assessment will need to achieve a minimum of 50% to pass. In the event a pass is not achieved you will be given one opportunity to resubmit your worksheet within 2 weeks from when you are notified of your result. The maximum marks allowed for a 2nd attempt will be 50%, if you are unsuccessful in achieving 50% with the resubmission you will need to repeat the entire unit.
Identify 5 nursing diagnosis relevant for this client. For diagnosis document
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Institute oxygen therapy, place the patient on bed rest in semi fowler’s to high fowler’s position with shoulders pulled back slightly if possible, and minimise environmental noise and distractions
These measures reduce the heart’s oxygen demand and help alleviate chest pain and ensuing anxiety. Chest and head elevation eases lung ventilation. Sitting with the shoulders pulled slightly back allows unrestricted movement of the diaphragm. Decreasing anxiety reduces circulating catecholamine levels, thus decreasing blood pressure and myocardial oxygen consumption.
Within 1 hour of chest pain onset, the patient will: Display vital signs within normal limits and display normal depth and rate of respirations

Obtain a 12 Lead ECG immediately during acute chest pain

Resting ECGs are usually normal in myocardial ischemia. Ischemic changes may be noted only during period of actual chest pain. ECGs also show abnormal
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When the patient is stable, institute a graduated activity program according to unit protocol. Begin with regular position changes and range of motion (ROM) exercises during bed rest. The, as tolerated, progress to active ROM exercises, chair sitting and ambulation.

Bed rest has many detrimental effects, including cardiac deconditioning, increased risk of atelectasis and pneumonia, and skin breakdown. It also promotes venous stasis, further increasing the risk of thromboembolism from depressed myocardial contractility and AF- an arrhythmia common in HF because of atrial distention. Position changes and exercises that involve a change in muscle length (such as active or passive limb flexion) improve peripheral circulation and reduce the risks associated with immobility.
By discharge, the patient will participate in a desired activity, meeting the needs of self-tolerance achieving increased activity, evidenced by a decrease in fatigue and weakness and vital signs during exercise

Provide the client with ideas for conserving
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