Assessment Diagnosis Planning Intervention Rationale Evaluation

- Receive client - Risk for - At the end 8 - Determine - To provide a - Goal met
lying in bed decreased hours of vital signs baseline data - At the end of
awake cardiac nursing - Note vital for 8 hours of
- Concious & output intervention signs response comparison nursing
coherent related to the client’s to procedures to follow intervention
- BP 80/60 decreased risk for trends and the client
- Feeling of circulation in decreased evaluate showed less
dizziness the heart cardiac response to risk for
- Decreased output will intervention cardiac
urine output be lessen output
- Weak pulse - Place client to - Decrease
a semi-fowler oxygen
position with consumption
feet slightly and risk for
elevated decompensa
tion

- Administer - To increase
high-flow oxygen for
oxygen via cardiac
mask or consumption
cannula

- v/s monitored

- provide safe
and calm
environment

- promote rest

- due meds
given
Risk for decreased cardiac output – NCP – COA - Potential