University of Perpetual Help System DALTA

Alabang – Zapote Rd., Pamplona Las Piñas City

COLLEGE OF NURSING
NURSING CARE PLAN

Name of Patient: Jaime Gamlanga Age: 79 years old Sex: M Diagnosis: Cardiac Arrythmia Rm. / Bed No.: 504

ASSESSMENT NURSING PLANNING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE: Ineffective tissue After 8 hours  Established  To gain client’s trust and Goal met. After 8
 “Ok naman ang perfusion related of nursing Rapport cooperation hours of nursing
pakiramdam ko,” as to impaired intervention, intervention, the
verbalized by the transport of O2 client will  Monitored and  To establish baseline data client manifested
client. across capillary demonstrate recorded vital signs regular and
membrane as increased  Monitored and  To determine fluid volume consistent pulse
OBJECTIVE: evidenced by perfusion with recorded Intake and relative to oxygen rhythm.
 Alert, awake weak, irregular manifestation Output transportation and
and responsive pulse rhythm. of regular pulse circulation
 (+)spontaneous, characteristics.
non-labored  Advised restful,  Quiet atmosphere
breathing quiet atmosphere conducive to rest alleviates
 Capillary refill stress which aids the heart
less than 4 in proper function
seconds
 (+) weakness
 (+) weak,  Cautioned to avoid  Activities that requires too
irregular pulse activities that much work load leads to
rate & rhythm increase the heart’s heart stress
 Temp – 36.4°C work load
 PR – 64 bpm  Administered  These medications promote
 RR – 20 cpm Carvedilol, proper circulation and
 BP – 120/80 Erdosteine and transportation of O2
mmHg Kalium Durule as
ordered

Name of Student: Bartolome, Rhoel John V Yr. Sec. & Grp No.: BSN 4D Group 4 Area & Shift: MCI 5th Floor Ward (2-10pm)