Mary Ganey

Nursing Diagnosis: R/F activity intolerance r/t ineffective cardiac tissue perfusion
Long-Term Goal: Pt will have effective tissue perfusion
Outcome
Criteria
One outcome criteria
for each intervention.
Number each one.

Interventions
Label each as
assess/monitor/independent/
dependent/teaching/collaboration

1. Pts VS will be
90-140/60-90, HR
60-100, T <100.4
qshift

1. Assess VS q4hrs

2. Pt will be
A&Ox3 qshift

2. Assess for changes in

LOC q2hrs

Rationale
Answers why, how, what your interventions will help solve, prevent,
Or lesson the stated problem specific to each patient.

1. Pt is a 84 yo female with PMH of anemia, CHF, CAD,

HTN, DM, hyperlipidemia, positive troponins. Due to her
chronic co-morbidities, she is at r/f decreased cardiac
tissue perfusion. It is important to monitor VS as
changes may indicate worsening CAD. Increased
plaque in the vessels cause an increase in BP d/t
narrowing of arteries which puts her at an increase for
vascular resistance. More force is required to pump
blood through diseased arteries, and this increased
force is reflected in a higher BP. An increase in HR may
occur as a compensatory mechanism, especially if the
coronary arteries are affected by atherosclerosis
because an adequate amount blood flow cannot
perfuse the cardiac tissue. Due to this patient having
positive troponins, myocardial cell death/injury may
cause an anti-inflammatory response and manifest as
an elevated temp. Worsening CAD leads to decreased
cardiac tissue perfusion which in turn, leads to
decreased peripheral perfusion and then will lead to
decreased activity tolerance.
2. Pt is a 84 yo female with PMH of anemia, CAD, CHF,
HTN, DM, hyperlipidemia, positive troponins. Pt is
A&Ox3 and becomes mildly SOB with exertion. Due to
her co-morbidities, age, and gender, she may
experience atypical signs of MI, including SOB,
indigestion, or fatigue. In older adults particularly, MI
may manifest as confusion and dizziness. She does not

Evaluation
Evaluate the patient
outcome, NOT the
intervention

1. Met: vital signs

remained WNL

2. Met: pt was A&Ox3

at all times

3. Pts skin will

remain pink,
warm, dry, and
free of pitting
edema qshift

3. Assess skin q2hrs

present with confusion on assessment, which implies

that even though she has positive troponins, her
cardiac function has not been interrupted in a way that
has impaired cerebral perfusion. If she presented with
an MI, that would decrease her cardiac tissue perfusion
as the injured area of the heart would not be getting
adequate blood supply thereby impairing perfusion to
the heart. Any changes in mentation may indicate a
new or extending MI, as well as decreased cerebral
perfusion d/t altered cardiac function. Older adults are
more susceptible to reduced perfusion to vital organs
such as the brain. Decreased cardiac tissue perfusion
will cause the pump the be ineffective which will lead
to decreased cerebral perfusion indicated by changes
in LOC such as disorientation, dizziness, confusion.
Changes in LOC put her at an increased r/f activity
intolerance, as the cardiac tissue and cerebral tissue
may be ineffectively perfused.
3. Pt is a 84 yo female with PMH of anemia,
hyperlipidemia, CHF, CAD, HTN, DM, positive troponins.
Tissue capillary oxygen extraction is increased in a
person with CHF and anemia, resulting in a pallor
appearance, especially at/around mucous membranes.
Due to positive troponins, pt is at an increased risk for
MI. During the initial phase of MI, the ischemic
myocardial cells release catecholamines
(norepinephrine & epinephrine) that are normally found
in these cells. This results in release of glycogen,
diaphoresis, and vasoconstriction of peripheral blood
vessels. On physical exam, pts skin may be ashen,
clammy, and cool to touch. CAD also plays a factor in
the appearance of skin. Because the vessels are
building up with plague, an adequate amount of blood
flow needed for perfusion cannot get through. If
adequate blood flow is not being supplied peripherally,
that means that cardiac tissue perfusion will also be

3. Met: skin was pale

but started to pink up
after 2 units of PRBCs,
she was free of edema

4. Pt will remain
free of CP qshift

4. Assess pain q2hrs

5. Pts O2 will
remain >95%
qshift

5. Assess O2 sats q4hrs

decreased and can cause the pump to act ineffectively.

Additionally, if the pt spends a great deal of time in
bed, sacral edema may develop. An increase in pitting
edema may indicate further decline in pump function,
and increases the risk for skin breakdown.
4. Pt is a 84 yo female with PMH of anemia, CHF, CAD,
HTN, hyperlipidemia, positive troponins. Pt had also
complained of back and left arm pain on admission
which could be symptomatic of an MI. Pain is usually
the first presenting sign of a new or extending MI. SNS
stimulation from anxiety and pain r/t MI stimulate the
SNS, increasing HR and BP and increasing the O2
demand on the myocardium, further exacerbating
ischemia. Pain can present in the chest d/t the cardiac
tissue not being perfused with oxygenated blood.
Myocardial cells are deprived of oxygen and glucose
needed for aerobic metabolism and contractility.
Anaerobic metabolism begins, and lactic acid
accumulates. Lactic acid irritates myocardial nerve
fibers and transmits a pain message to the cardiac
nerves and upper thoracic posterior nerve roots. When
the demand for myocardial oxygen exceeds the ability
of the coronary arteries to supply and perfuse the heart
with oxygen, myocardial ischemia occurs. Severe pain,
unrelieved by rest and/or administration of NTG,
described as crushing, pressure, tightness, burning, or
constriction in the chest should be taken very seriously
and reported as soon as possible. It is important to
note that women and older adults often experience
atypical symptoms; pain may not always be present,
but should be taken seriously nonetheless. She should
be instructed to report any new onset pain to the HC
team as soon as possible.
5. Pt is a 84 yo female with PMH of anemia, CHF, CAD,
HTN, DM, hyperlipidemia, positive troponins. Because
the cause of MI pain is ischemia, or lack of sufficient O2

4. Met: pt remained
free of CP

5. Met: pts O2 stayed

at 100% on room air

6. Pt will not c/o

CP with activity
qshift

6. Assess response to
activity qshift

7. Pt will
complete ADLs
with assistance
without fatigue
qshift

7. Provide paced nursing

care at all times

to meet the needs of the heart muscles O2 demands,

her O2 sats should be monitored frequently to maintain
oxygen saturation levels of <95% to ensure adequate
cardiac, cerebral, and peripheral perfusion. Decline in
O2 sats may indicate decline in cardiac function. An
individual with a long history of CAD develops collateral
circulation to provides areas of the cardiac tissue
surrounding any areas of ischemia with a blood supply
to ensure adequate cardiac tissue perfusion.
Oxygenated blood is also necessary to maintain
adequate cardiac tissue perfusion which is why it is
important to maintain O2 saturation levels <95%.
6. Pt is a 84 yo female with PMH of anemia, CHF, CAD,
HTN, DM, hyperlipidemia, postitive troponins. Due to
her co-morbidities, this pt could quickly decline with
significant myocardial tissue death and further reduced
cardiac tissue perfusion. Her positive troponins and
CAD put her at an increased r/f decreased cardiac
tissue perfusion as the vessels are building up with
plaque, the pump is working harder to push blood
through those vessels to increase perfusion to the rest
of the body. If the blood cannot adequately perfuse the
body, the cardiac tissue perfusion will be decreased as
well, causing the pump not to work effectively. A
decrease in activity tolerance may indicate a
worsening of CAD which leads to decreased cardiac
tissue perfusion and ultimately a decrease in peripheral
perfusion.
7. Pt is a 84 yo female with PMH of anemia, CHF, CAD,
HTN, DM, hyperlipidemia, positive troponins. While
activity and position change should be encouraged to
prevent fluid settling, it is important that
encouragement to do so and assistance with ADLs be
paced. In addition, this pt has a very low hemoglobin
level of 7.9 which will cause her to fatigue quicker.
Paced activities reduce cardiac workload. Overexertion

6. Met: pt ambulated
without c/o

7. Met: pt completed
ADLs with assistance
without c/o fatigue

8. Pts Hgb will

be 12-16, Hct 3648 daily

8. Monitor Hgb and Hct

daily

9. Pt will not
develop any
dysrhythmias
during
hospitalization

9. Place pt on continuous
telemetry throughout
hospitalization

with decreased cardiac tissue perfusion may lead to an

ischemic event and further decline in pump function.
Increased activity increases O2 demand to the
myocardium therefore the heart works harder and if
the pump is working harder, there is an increase need
for O2 which increase r/f myocardial cell
death/ischemia. Attention should be paid to priority
care and care delivered in a way that maximizes this
pts already limited energy sources. Both physical and
emotional rest conserve energy and place less stress
on the CV system.
8. Pt is a 84 yo female with PMH of anemia, CHF, CAD,
HTN, DM, hyperlipidemia, positive troponins. Hgb is
used to measure the severity of anemia and it monitors
the treatment of anemia. Hgb is the oxygen-carrying
compound contained in each erythrocyte. The large
amount of Hgb and the broad surface area of each
erythrocyte enable the red blood cells to have a large
oxygen-carrying capacity and to function with great
efficiency. With low Hgb levels, the oxygen in blood is
decreased thereby decreasing cardiac tissue perfusion.
The lack of Hgb in the erythrocytes is often due to lack
of iron, an essential mineral used to make heme, the
iron-containing molecule of Hgb. The Hct is a
measurement of the proportion of whole blood volume
occupied by erythrocytes. When Hct is low, the
severity of the drop in value correlates directly with the
amount of red blood cells that are lost. Blood
transfusion and iron supplements should be
considered, especially in this pt, who has very low Hgb
and Hct levels.
9. Pt is a 84 yo female with PMH of anemia, CHF, CAD,
HTN, hyperlipidemia, positive troponins. Telemetry
monitoring allows for detection of dysrhythmias,
including tachycardia, which may be indicative of
decreasing cardiac tissue perfusion as a compensatory

8. Unmet: pts Hgb was

7.9, Hct 23.1

9. Met: pts telemetry

strip remained in NSR

10. Pts O2 will be

95-100% qshift

10. Provide supplemental

O2 via NC PRN SOB/CP

11. Pts troponin

will decrease
throughout serial

11. Monitor troponin I series

q6hrsx3

mechanism. Changes in the ST segment may indicate

infarction or ischemia. This provides an additional
measure to assess for signs of MI, since this pt is both
elderly and female and may experience atypical
symptoms of an MI that could go undetected. During
ischemia, ST segment depression and/or T wave
inversion may present. Due to this patients comorbidities, it is important to monitor telemetry for
indicators of decreased cardiac tissue perfusion so that
rapid action can be taken and the problem can be
resolved quickly.
10. Pt is a 84 yo female with PMH of anemia, CHF,
CAD, HTN, DM, hyperlipidemia, positive troponins. A
result from insufficient O2 to meet myocardial O2
demand is cardiac ischemia/death. Supplemental
oxygen should be available for this patient and applied
as soon as possible with onset s&s of chest pain and/or
other MI s&s. The supplemental O2 will increase the
supply of O2 to the heart and possibly reverse any
hypoxic injury to cardiac tissues. With a dx of CAD, it is
harder for the heart to be perfused effectively with
oxygenated blood because the arteries and vessels
have a build up of plaque. Due to this, the pump has
to work harder to push blood throughout the body,
thereby increasing BP and HR and decreasing cardiac
tissue perfusion. While this patient becomes mildy
SOB with exertion, supplemental oxygen will help to
increase oxygen saturation by supplying the lungs with
enough air so that gas can be exchanged properly in
the alveoli, promoting increased gas exchange which in
turn results in the blood being oxygenated and
perfused appropriately to cardiac, cerebral, and
peripheral tissues.
11. Pt is a 84 yo female with PMH of CHF, anemia,
CAD, HTN, DM, hyperlipidemia, positive troponins.
Troponin I, a cardiac-specific protein released in

10. Met: pts O2

remained at 100%

11. Partially met:

Troponin started at
0.10, increased to 1.20

lab draw

12. Pts Hgb will

be 12-16, Hct 3648, RBC 4.2-5.4
after transfusion
of PRBC

12. Transfuse PRBCs as

ordered

response to myocardial injury, is the gold standard

lab draw by which acute MI, even without EKG data, is
diagnosed. Troponin is found only in the cardiac
muscle complex, therefore, it is very specific to cardiac
injury. An MI occurs because of sustained ischemia,
causing irreversible myocardial cell death. The location
of the infarction correlated with the involved coronary
circulation. Due to this pts PMH of CAD, the coronary
arteries have developed atherosclerosis, which impairs
blood flow through the vessels, therefore the cardiac
tissue is not being perfusion effectively. When an
adequate amount of oxygenated blood cannot perfuse
the heart effectively, myocardial cell injury/death
occur. When this occurs, troponin levels will increase,
showing HCPs that immediate action is necessary to
prevent worsening of an MI.
12. Pt is a 84 yo female with PMH CHF, CAD, HTN, DM,
hyperlipidemia and admitting diagnosis of anemia. She
had an admitting hgb level of 6.3, hct 19.3, RBC 2.03.
A pt, such as this, suffering from an iron deficiency or
anemia, a condition where the body does not have
enough red blood cells, may receive a blood
transfusion. This type of transfusion increases the pts
hgb and iron levels, while improving the amount of
oxygen in the body. The transfusion of red cell
concentrates is indicated in order to achieve a fast
increase in the supply of oxygen to the tissues, when
the concentration of hgb and/or the oxygen carrying
capacity is reduced, in the presence of inadequate
physiological mechanisms of compensation. With this
pts co-morbidities, she is at an increased r/f decreased
cardiac tissue perfusion. CAD does not allow adequate
blood flow through the vessels to promote effective
cardiac tissue perfusion d/t the build up of plaque in
the vessels. Anemia will also put her at risk for
deceased cardiac tissue perfusion because her entire

and then decreased to

0.86

12. Unmet: pts Hgb

7.9, Hct 23.1, RBC
2.47 after PRBC
infusion

13. Pt will be
free of pitting
edema daily

13. Administer furosemide

40mg po daily

14. Pts HDL will

be 40-60mg/dL,
LDL 0-99mg/dL,
triglycerides 0149, and
cholesterol 120200 daily

14. Administer atorvastatin

20mg po daily

15. Administer losartan

blood count is low. When the blood count is low,

cardiac, cerebral, nor peripheral tissues can be
perfused effectively. All of these factors will decrease
her activity intolerance as none of the tissues are being
perfused adequately and will result is fatigue,
increased BP, HR, possible confusion and dizziness
13. Pt is a 84 yo female with PMH of CHF, CAD, HTN,
DM, anemia, hyperlipidemia, positive troponins.
Furosemide is a potent loop diuretic prescribed to
increase excretion of Na+ and H2O. By blocking
reabsorption of water and Na+ at the distal loop of
Henle in the kidney, it mobilizes excess fluids. In
mobilizing excess fluids, PVR is decreased, thus
reducing blood pressure. In reducing blood pressure,
the workload of her functionally-altered heart is
decreased, as it has less pressure to pump against. A
decreased BP will help the cardiac tissue be perfused
effectively as it is not working so hard to compensate.
When the heart is perfused, BP is lowered, and the
workload is decreased, it should increase her activity
tolerance because the heart is able to pump effectively
and perfuse cerebral and peripheral tissues as well.
14. Pt is a 84 yo female with PMH of hyperlipidemia,
anemia, HTN, CAD, CHF, DM, positive troponins. Most
MI events are precipitated by atherosclerotic plaques in
the coronary arteries. This causes narrowing of the
artery lumen, and creates the potential for a plaque to
become unstable, rupture, and then become a site for
platelet aggregation. If platelets aggregate and cause
total occlusion, the result is a STEMI. In an effort to
reduce the risk of plaque formation and disruption and
slow the progression of CAD, statins are prescribed to
lower overall triglycerides. Atorvastatin inhibits an
enzyme, 3-hydroxy-3-methylglutaryl-coenzyme A
reductase, which is responsible for catalyzing an early
step in the synthesis of cholesterol.

13. Met: pt had no

pitting edema

14. Unmet: lipid labs

not drawn

15. Met: pts BP and HR

15. Pts BP will be

90-140/60-90, HR
60-100 qshift

50mg po daily

remained WNL
15. Pt is a 84 yo female with PMH of CHF, CAD, HTN,
anemia, hyperlipidemia, positive troponins. Losartan is
an antihypertensive, angiotensin II receptor antagonist.
It blocks vasoconstriction and aldosterone-producing
effects of angiotensin II at receptor sites, including
vascular smooth muscle and adrenal glands. This
medication is important for this patient because it
works against a few of her past medical history
diseases. It lowers BP, slows progression of diabetic
neuropathy, and decreases risk of stroke in pts with
HTN and left ventricular hypertrophy. Increased plaque
in the vessels (CAD) cause an increase in BP d/t
narrowing of arteries which puts her at an increase for
vascular resistance. More force is required to pump
blood through diseased arteries, and this increased
force is reflected in a higher BP. This medication will
increase cardiac output and in turn increase cardiac
tissue perfusion as well as perfusion to the rest of the
body thereby allowing her to tolerate activity.