EA: How your child's nurse can help

Analyze nursing care of individuals with your disease for the most current information. Identify key websites that you recommend as part of your blog in this area.

Nursing Plan for Ebstein’s Anomaly Treatment

Diagnosis 1.

Activity intolerance related to insufficient oxygenation secondary to inefficient blood flow through the pulmonary artery as evidenced by weakness, fatigue, shortness of breath, changes in pulse rate and changes in blood pressure.

Let’s break it down:

Problem	Related To	Plan	Outcome	Nursing Interventions
Activity intolerance	Insufficient oxygenation	To achieve optimal activity level	-To breathe easily during activity. -To maintain an adequate and acceptable blood pressure (age dependent) during activity. -To maintain and adequate and acceptable pulse rate (age dependent) during activity.	-Monitor pulse rate and blood pressure in response to activity. -Encourage alternating periods of rest and activity to conserve energy and decrease demands on the heart. -Encourage activities to gradually build endurance to increase cardiac tolerance. -Assist the patient and caregiver to establish realistic exercise goals to promote the patient’s health and sense of accomplishment.

Diagnosis 2.

Risk for excess fluid volume related to fluid retention secondary to tricuspid value induced right heart failure as evidenced by peripheral edema, weight gain, adventitious breath sounds, and/or jugular venous distension.

Diagnosis 3.

Decreased cardiac output related to tricuspid valve insufficiency as evidenced by murmurs, dyspnea, and peripheral edema.

Diagnosis 4.

Impaired gas exchange related to insufficient blood flow to the lungs through the pulmonary artery as evidenced by abnormal oxygen saturation, dyspnea, restlessness, or the statement “I feel short of breath.”

Diagnosis 5. 
Altered Nutrition: Less than body requirements related to difficulty breathing while eating as evidenced by prolonged feeding time, increased respiratory rate between latching or chewing and swallowing, weight loss.


References:
1. Lewis LL, Dirksen SR, Heitkemper MM, et al. Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Edition 9. 2014. Elsevier Health Sciences.