NURSING CARE PLAN
CUES DIAGNOSIS
Subjective:
“luya kayo akong paminaw”
as verbalized by the patient
Objective:
 Change in level of
consciousness
 Crackles, dyspnea,
orthopnea,
tachypnea
 Decreased activity
tolerance/fatigue
 Decreased venous
and arterial
oxygen saturation
PLANNING INTERVENTION RATIONALE EVALUATION
Decreased cardiac Short Term:  Diagnoses that may create a Within 8 hours of nursing
output r/t decreased Within 8 hours of  Prepare for assist with fluid volume depletion interventions, the patient
venous return s/t nursing diagnostic evaluations (such as rapid blood loss or was able to understand
Hypertensive interventions, the  Monitor active fluid loss hemorrhage/ bleeding) causative factors and
Cardiovascular patient participate from bleeding  To locate source of bleeding purpose of individual
Desease in activities that  Assess vital signs, noting therapeutic interventions,
reduce blood low blood pressure  To determine how much surgical procedures and
pressure or cardiac blood is lost from the body medications as evidenced
work load.  In an acute, life threatening by verbalization of
hemorrhage state, cold, pale, “operahan man ko, kuhaon
Long Term: moist skin may be noted akong tibuok matres para
 Review laboratory reflecting body mayo nako”
Within 3 days of findings such as compensatory mechanisms GOAL MET
nursing hemoglobin, hematocrit to profound hypovolemia.
interventions, the  Control blood loss and  To evaluate body’s response
patient prepare for surgical to bleeding and to determine
demonstrates interventions such as total replacement needs
adequate cardiac
abdominal hysterectomy  To correct
output as
 Encourage patient to pathophysiological
evidenced by
acknowledge and express mechanisms
blood pressure and
fears
pulse rate and
 Provides opportunity for
rhythm within
normal parameters dealing with concerns,

for patient; strong  Identify previous coping clarifies reality of fears, and
peripheral pulses; strengths of the patient reduces anxiety to
and an ability to and current areas of manageable level
tolerate activity control or ability  Focuses attention on own
without symptoms  Advised patient to eat capabilities, increasing
of dyspnea, foods rich in iron such as sense of control
syncope, or chest green leafy vegetables
pain.  Provide oral as well as eye  To help correct iron-
care deficiency

COLLABORATIVE:  To prevent injury from

 Administer blood products dryness
as ordered

COLLABORATIVE:
 To replace blood that were
lost from the body due to
vaginal bleeding