Cues: Subjective/ Objective Snanghihina nga ako at medyo nahihirapang huminga, as verbalized by the patient.

Background of the disease Decreased ventricular contraction

Nursing diagnosis

Goal/ Objectives Intervention Rationale Evaluation

Decreased cardiac output related to

Goal To demonstrate hemodynamic stability including blood pressure, cardiac output, renal perfusion/urine output, and peripheral pulses.

Independent: 1. Place patient in semifowlers position, and may elevate legs 20-30 degrees in shock situation 2. Monitor vital signs -to note response to activities/ interventions 3. Monitor cardiac rhythm continuously -to note effectiveness of medications and/or -decreases oxygen consumption and risk of decompression.

Goal partially met

After 8 hours of nursing interventions the patient was able report decrease episodes of dyspnea, and angina. Dysarythmias were still evident when

Ventricular overload

altered afterload and

Altered ability to pump

contractility of the heart secondary to congestive heart failure

O- difficulty of breathing -orthopnea -edema on both feet -decreased peripheral pulse -crackles Vital signs: RR -24 cpm

enough oxygenated blood to meet the bodys metabolic requirements

Objectives After 8 hours of nursing interventions,

assistive devices like implanted pacemaker

increased heart rate, vasoconstricti on, and

the patient will be able: a. Report/ demonstrate

4. Assess urine output hourly or periodically and weigh the client daily noting total fluid

-to allow for timely alterations on therapeutic regimen

auscultated. The patient had an increase on

HR -121 bpm

hypertrophy

decrease episodes of

balance 5. Monitor rate of IV drugs closely, using infusion pumps as appropriate 6. Provide quiet and comfortable environment 7. Assist with or perform self-care activities for client -to limit activities that will decrease oxygen consumption 8. Provide information about testing procedures and dietary/fluid restrictions 9. Provide psychological support. Maintain a calm attitude but admit concerns if questioned by client -to promote client participation on the therapeutic regimen -honesty can be reassuring when so much activities and worry are apparent to the client. -to promote adequate rest. -to prevent bolus/overdose

activity tolerance and participates in activities that reduce cardiac workload. RR 22 cpm HR 112 bpm

decreased cardiac output

dyspnea, angina and dysarythmia b. Demonstrate an increase in activity tolerance c. Verbalize knowledge of the disease process, individual risk factors and treatment plan d. Participate in activities that reduce workload of the heart.

Dependent: 1. Administer oxygen via nasal cannula or mask -to increase oxygen available for

as indicated

cardiac function and tissue perfusion

2. Administer fluid replacement, antibiotics and/or diuretics as indicated

-to prevent or alleviate the symptoms of fluid retention

3. Administer analgesics

-to promote comfort/rest