PHINMA UNIVERSITY OF PANGASINAN

COLLEGE OF HEALTH SCIENCES

Nursing Department
NURSING CARE PLAN
NURSING NURSING
ASSESSMENT PLANNING NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS ANALYSIS

SUBJECTIVE: Decreased Inadequate Short Term Goal: Review clients at risk as noted in Persons with acute or chronic Goal met. The
Cardiac blood pumped Related Factors as well as conditions may compromise patient’s cardiac
Patients complaints Output r/t by the heart to Demonstrate stable individuals with conditions that stress circulation and place output returns to it
of weakness anesthetic meet metabolic cardiac rhythm and the heart. excessive demands on the normal range.
drugs demands of the rate within patient’s heart.
OBJECTIVE: body. normal range.
Hypotension is
Hypotension commonly Monitor and record BP. Measure in Comparison of pressures
Tachycardia encountered in both arms and thighs provides a more complete
Confusion association with picture of vascular
Cool extremeties anaesthesia and involvement or scope of
surgery problem.

Note presence, quality of central Bounding carotid, jugular,

and peripheral pulses.
radial, and femoral pulses
may be observed and
palpated. Pulses in the legs
and feet may be diminished,
reflecting effects of
vasoconstriction (increased
systemic vascular resistance
[SVR]) and venous
congestion.

Provide comfort measures. Decreases discomfort and

may reduce sympathetic
stimulation.

PREPARED BY: Cruz, Rosalia C.