Mr. Garcia came to the emergency department complaining of chest pain unrelieved by nitroglycerin (NTG) and rest. He was admitted to the coronary care unit with a diagnosis of unstable angina. During the physical assessment, the nurse discovers that Mr. Garcia has a history of MI with a coronary artery bypass graft surgery four years ago. Over the past year, he has had increasing shortness of breath, intermittent chest pain relieved with rest, and generalized fatigue. He complains of being unable to work the long days he used to as a carpenter and requires several 15–20-minute rest periods throughout the day. His physical examination reveals diminished breath sounds in the bases of his lungs, mild tachycardia, diaphoresis, and capillary refill greater than 3 seconds.
ASSESSMENT
This patient has a history of cardiac disease with an increase in chest pain, fatigue, and shortness of breath. The results of the physical examination (diminished breath sounds in the lungs, tachycardia, and decreased capillary refill) indicate problems with oxygenation and tissue perfusion. The patient’s expressed concern about fatigue and frequent rest periods indicates a need for conservation measures. Levine’s Theory of Conservation will be a good fit as a plan of care is implemented.
NURSING DIAGNOSIS #1:
Activity intolerance related to poor oxygenation as evidenced by complaints of shortness of breath, chest pain, and the need for frequent rest periods during activities.
EXPECTED OUTCOMES
The patient will:
1. No longer complain of shortness of breath during activity.
2. Have no episodes of chest pain during activity
PLANNING/INTERVENTION/RATIONALE
1. Review therapeutic regimen with patient (e.g., medications, activities, and rest periods). Following therapeutic regimen, such as taking medications to improve cardiac function and increase urinary output, decreasing and eliminating shortness of breath and chest pain. Preserves structural integrity.
2. Assist patient in planning rest periods during periods of physical activity, such as construction work. Allows for conservation of energy to complete activities with decreased stress and anxiety.
EVALUATION
Patient experienced no shortness of breath or chest pain and is following therapeutic regimen at home. Patient took rest periods at least every three to four hours and was able to complete his day of work without as much fatigue within three weeks of being discharged.
NURSING DIAGNOSIS #2:
Fatigue related to poor oxygenation as evidenced by complaints of inability to complete a day of work without fatigue and continued shortness of breath.
EXPECTED OUTCOMES
The patient will:
1. State his energy levels are greater in one week and will be able to complete normal days of construction work within three weeks.
2. Not experience tachycardia or shortness of breath after returning to work and normal activities of daily living.