Possibly evidenced by
Alterations in heart rate and BP with activity
Development of dysrhythmias
Changes in skin color and moisture
Desired Outcomes/Evaluation Criteria—Client Will
Demonstrate measurable, progressive increase in tolerance for activity with heart rate and rhythm, BP within client’s normal
limits, and skin warm, pink, and dry.
Report absence of angina with activity.
Nursing intervention with rationale:
1. Record and document heart rate and rhythm and BP changes before, during, and after activity, as indicated. Correlate with reports of chest pain or shortness of breath.
Rationale: Trends determine client’s response to activity and may indicate myocardial oxygen deprivation that may require decrease in activity level, return to bedrest, changes in medication regimen, or use of supplemental oxygen.
2. Encourage bedrest to chair rest initially. Thereafter, limit activity on basis of pain or adverse cardiac response. Provide nonstress diversional activities.
Rationale: Reduces myocardial workload and oxygen consumption, reducing risk of complications, such as extension of MI. Clients with uncomplicated MI are encouraged to engage in mild activity out of bed, including short walks 12 hours after incident.
3. Instruct client to avoid increasing abdominal pressure, such as straining during defecation.
Rationale: Activities that require holding the breath and bearing down, such as Valsalva’s maneuver, can result in bradycardia with temporarily reduced cardiac output and rebound tachycardia with elevated BP.
4. Explain pattern of graded increase of activity level, such as getting up to commode or sitting in chair, progressive ambulation, and resting after meals.
Rationale: Progressive activity provides a controlled demand on the heart, increasing strength and preventing overexertion.
5. Review signs and symptoms reflecting intolerance of present activity level or requiring notification of nurse or physician.
Rationale: Palpitations, pulse irregularities, development of chest pain, or dyspnea may indicate need for changes in exercise regimen or medication.
1. Refer to cardiac rehabilitation program.
Rationale: Provides continued support and additional supervision and promotes participation in recovery and wellness process.