Question

submit a care plan with three common interventions with rationals and evaluation for a patient with osteoarthritis and cardiomyopathy.

Answer 1

Nursing care plan for osteoarthritis

1. Acute pain /chronic pain reated to joint degeneration secondary  to osteoarthrirts evidenced by decreased ability to perform ADLs

Nursing intervention	Rationale
Assess the client’s description of pain.	The client may report pain in the fingers, hips, knees, lower lumbar spine, and cervical vertebrae. Pain is usually provoked by activity and relieved by rest; joint pain and aching may also be present when the client is at rest. Pain may manifest as an ache, progressing to sharp pain when the affected area is brought to full weight-bearing or a full range of motion (ROM). The client may experience sharp, painful muscle spasms and paresthesias.
Apply a hot or cold pack.	Heat reduces pain through improved blood flow to the area and through the reduction of pain reflexes. Special attention needs to be given to preventing burns with this intervention. Cold reduces pain, inflammation, and muscle spasticity by decreasing the release of pain-inducing chemicals and slowing the conduction of pain impulses. These interventions require no special equipment and can be cost-effective. Hot or cold applications should last about 20 to 30 min/hr.
Support joints in a slightly flexed position through the use of pillows, rolls, and towels.	Flexion of the joints may reduce muscle spasms and other discomforts.

Evaluation : Patient will engage in desired activities without an increase in pain level .

2. Imapaired physical mobility realted to fatigue and muscle weakness secondary to osteoarthritis evidenced by decreased range of motion

Nursing intervention	Rationale
Assess the client’s posture and gait.	It is important to assess for indicators of a decreased ability to ambulate and move purposefully: shorter steps, making gait appear unstable; uneven weight-bearing; an observable limp; or rounding of the back or hunching of the shoulders.
Encourage the client to increase activity as indicated.	Increasing activity at home can be effective in maintaining joint function and independence. A balance must exist between the client performing enough activity to keep joints mobile and not taxing the joint too much.
Consult physical therapy staff to prescribe an exercise program.	The physical therapist can help the client to promote muscle strength and joint mobility and therapies to promote the relaxation of tense muscles. These interventions also may contribute to effective pain management.

Evaluation: Patient will perform physical activity independently or within limits of activity restrictions.

3. Activity intolerance realted to decrteased muscle tone secondary to osteoarthritis evidenced by joint pain

Nursing intervention	Rationale
Assess the physical activity level and mobility of the client.	Provides baseline information for formulating nursing goals during goal setting.
Assess the client’s nutritional status.	Adequate energy reserves are needed during activity.
Assess the need for ambulation aids (e.g., cane, walker) for ADLs.	Assistive devices enhance the mobility of the patient by helping him overcome limitations.

Evaluation: Patient  will use identified techniques to enhance activity intolerance

4. Risk for injury ralted to altered mobility

Nursing intervention	Rationale
Assist client with active and passive ROM exercises and isometrics as tolerated.	Maintains and enhances muscle strength, joint function, and endurance.
Encourage client to lose weight to decrease stress on weight-bearing joints.	Excess weight adds extra stress on the joints, which can accelerate joint cartilage deterioration.
Use a buffer bed and positioning the bed as low when sleeping.	This will reduce possible injury from falling during sleep.
Instruct the client to use the softest surface available during exercise.	A soft and flat surface minimizes shaking of client’s joints and chances of hurtful steps that could aggravate the condition.

evaluation:Patient will be free of injuries.

Nursing care plan for Cardiomyopathy

1. Decreased cardiac out put related to impaired contractability secondary to cardiomyopathy evidenced by altered heart rate

Nursing intervention	Rationale
Record intake and output. If patient is acutely ill, measure hourly urine output and note decreases in output.	Reduced cardiac output results in reduced perfusion of the kidneys, with a resulting decrease in urine output.
For patients with increased preload, limit fluids and sodium as ordered.	Fluid restriction decreases extracellular fluid volume and reduces demands on the heart.
Closely monitor fluid intake including IV lines. Maintain fluid restriction if ordered.	In patients with decreased cardiac output, poorly functioning ventricles may not tolerate increased fluid volumes.
Auscultate heart sounds; note rate, rhythm, presence of S3, S4, and lung sounds.	The new onset of a gallop rhythm, tachycardia, and fine crackles in lung bases can indicate onset of heart failure. If patient develops pulmonary edema, there will be coarse crackles on inspiration and severe dyspnea.

Evaluation:Patient demonstrates adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for patient

2. Activity intolerance related to Imbalance between oxygen supply and demand secondary to cardiomyopathy evidenced by general weakness and fatigue

Nursing intervention	Rationale
Establish guidelines and goals of activity with the patient and/or SO.	Motivation and cooperation are enhanced if the patient participates in goal setting.
Evaluate the need for additional help at home.	Coordinated efforts are more meaningful and effective in assisting the patient in conserving energy.
Have the patient perform the activity more slowly, in a longer time with more rest or pauses, or with assistance if necessary.	Helps in increasing the tolerance for the activity.
Gradually increase activity with active range-of-motion exercises in bed, increasing to sitting and then standing.	Gradual progression of the activity prevents overexertion.

Evaluation:Patient will report the ability to perform required activities of daily living

3. Excess fluid volume ralted to decreased cardiac out put secondary to cardiomyopathy evidenced by edema

Nursing intervention	Rationale
Instruct patient, caregiver, and family members regarding fluid restrictions, as appropriate.	Information and knowledge about condition are vital to patients who will be co-managing fluids.
Limit sodium intake as prescribed.	Restriction of sodium aids in decreasing fluid retention
Monitor fluid intake.	This enhances compliance with the regimen.
Take diuretics as prescribed.	Diuretics aids in the excretion of excess body fluids.

Evaluation:Patient has balanced intake and output and stable weight.

4. Ineffective tissue perfusion related to hypoventilation secondary to cardiomyopathy evidenced by abnormal arterial blood gases

Nursing intervention	Rationale
Submit patient to diagnostic testing as indicated.	A variety of tests are available depending on the cause of the impaired tissue perfusion. Angiograms, Doppler flow studies, segmental limb pressure measurement such as ankle-brachial index (ABI), and vascular stress testing are examples of these tests.
Check for optimal fluid balance. Administer IV fluids as ordered.	Sufficient fluid intake maintains adequate filling pressures and optimizes cardiac output needed for tissue perfusion.
Note urine output.	Reduce renal perfusion may take place due to vascular occlusion.
Maintain optimal cardiac output.	This ensures adequate perfusion of vital organs.

Evaluation:Patient maintains maximum tissue perfusion to vital organs, as evidenced by warm and dry skin, present and strong peripheral pulses, vitals within patient’s normal range

5. Impaired gas exchange related to Altered oxygen-carrying capacity of blood secondary to cardiomyopathy evidenced by Abnormal arterial blood gasses

Nursing intervention	Rationale
Position patient with head of bed elevated, in a semi-Fowler’s position (head of bed at 45 degrees when supine) as tolerated.	Upright position or semi-Fowler’s position allows increased thoracic capacity, full descent of diaphragm, and increased lung expansion preventing the abdominal contents from crowding.
Regularly check the patient’s position so that he or she does not slump down in bed.	Slumped positioning causes the abdomen to compress the diaphragm and limits full lung expansion.
If patient has unilateral lung disease, position the patient properly to promote ventilation-perfusion.	Gravity and hydrostatic pressure cause the dependent lung to become better ventilated and perfused, which increases oxygenation. When the patient is positioned on the side, the good side should be down (e.g., lung with pulmonary embolus or atelectasis should be up). However, when conditions like lung hemorrhage and abscess is present, the affected lung should be placed downward to prevent drainage to the healthy lung.
Turn the patient every 2 hours. Monitor mixed venous oxygen saturation closely after turning. If it drops below 10% or fails to return to baseline promptly, turn the patient back into a supine position and evaluate oxygen status.	Turning is important to prevent complications of immobility, but in critically ill patients with low hemoglobin levels or decreased cardiac output, turning on either side can result in desaturation.

Evaluation:Patient maintains optimal gas exchange as evidenced by usual mental status, unlabored respirations at 12-20 per minute, oximetry results within normal range, blood gases within normal range, and baseline HR for patient

5. Risk for Impaired Skin Integrity related to decreased tissue perfusion secondary to cardiomyopathy

Nursing intervention	Rationale
Discourage the patient or caregiver from elevating the head of bed repeatedly. Encourage the use of lifting devices like trapeze or bed linen to move the patient in bed.	Common causes of impaired skin integrity is friction which involves rubbing heels or elbows toward bed linen and moving the patient up in bed without the use of a lift sheet. A common cause of shear is elevating the head of the patient’s bed: the body’s weight is shifted downward onto the patient’s sacrum.
Encourage the patient to change position every 15 minutes and change chair-bound positions every hour.	During sitting, the pressure over the sacrum may exceed 100 mm Hg. The pressure needed to close capillaries is around 32 mm Hg; any pressure above 32 mm Hg leads to ischemia.
For low-risk patients: good-quality (dense, at least 5 inches thick) foam mattress overlay	Eggcrate-type mattresses less than 4 to 5 inches thick do not relieve pressure. Because they are made of foam, moisture can be trapped. A false sense of security with the use of these mattresses can delay initiation of devices useful in relieving pressure.
For moderate-risk patients: water mattress, static or dynamic air mattress	Dynamic devices electronically alternate inflation and deflation of the device. Static devices consist of gel, foam, water, or air that remains in a constant state of inflation. In the home, a waterbed is a good alternative.

Evaluation:Patient’s skin remains intact, as evidenced by the absence of redness over bony prominences and capillary refill less than 6 seconds over areas of redness