Name of Patient: Cardio Dalisay Room #: 199

Age:56 Attending Physician: Dr.Jimjim de la Cruz

Sex: M Diagnosis: Congestive Heart Failure

Nursing Nursing
Assessment Rationale Planning Rationale Evaluation
Diagnosis Interventions
Subjective: Short term Goal: Independent: Short term:
“My feet are Failure of the left After 8 hours of 1. Place in semi-  May promote
swelling and I can’t
Fluid Volume and/or right nursing Fowler’s position as recumbency-induced After 8 hours of nursing
move at all” Excess related chambers of the interventions the appropriate diuresis and facilitate interventions the patient
to heart results in patient will be able respiratory effort was not able to
Objective: inability to provide to demonstrate when movement of demonstrate coping
 Bipedal pitting
compromised sufficient output coping behaviors in the diaphragm is behaviors in reducing fluid
edema (+3) regulatory to meet tissue reducing fluid limited/ breathing is volume excess
 Crackles sound mechanism needs and causes volume excess: impaired  Bipedal pitting
noted upon Pulmonary  decrease (Source: 14th edition edema (+3)
auscultation
(heart failure) congestion, peripheral Nurse’s Pocket Guide,  Crackles sound
 T: 35.6 °C leading to edema Doenges, noted upon
 PR: 118bpm pulmonary  decrease Moorhouse, Murr, auscultation
 RR: 25cpm interstitial edema lung crackles p.343)  T: 36 °C
 BP: 80/50 and edema of the  increase  PR: 100 bpm
mmHg lower extremities. urine output 2. Elevate edematous  To reduce tissue  RR: 20 cpm
 O2 sat: 94-95%  vital signs extremities, change pressure and risk for  BP: 100/60 mmHg
 Decreased urine (Source: 11th within position frequently skin breakdown.  O2 sat: 94-95%
output – 500 edition Medical- acceptable (Source: 12th edition  increased urine
mL per day Surgical Nursing, range Nurse’s Pocket Guide, output / 600 mL
 X-ray Findings: Smeltzer, Bare, Doenges,
Normal heart Hinkle et al. p.950) Moorhouse, Murr,
size. Interstitial p.378)
and perihilar
butterfly Long Term Goal: 3. Auscultate breath  May indicate Long Term:
pattern alveolar After 1-2 days of sounds for presence of pulmonary edema
pulmonary nursing crackles secondary to cardiac After 1-2 days of nursing
edema. intervention, the decompensation intervention, the patient
patient will be able (Source: 3rd edition was not able to
to demonstrate Nursing Care Plans, demonstrate
interventions to Doenges, improvement to stabilize
stabilize fluid Moorhouse, Geissler fluid volume
volume p.91)

4. Compare current  Sudden changes in Goal partially met

weight with admission weight reflect
and/or previously alterations in fluid
stated weight balance
(Source: 3rd edition
Nursing Care Plans,
Doenges,
Moorhouse, Geissler
p.92)

5. Keep feet dry and  Prolonged immobility

provide padding as and bed rest are
indicated cumulative stressors
which affects the skin
integrity
(Source: 3rd edition
Nursing Care Plans,
Doenges,
Moorhouse, Geissler
p.56)
6. Instruct patient  Information and
regarding fluid knowledge about
restriction as condition are vital to
appropriate patients who will be
comanaging fluids
(Source: 11th edition
Medical- Surgical
Nursing, Smeltzer,
Bare, Hinkle et al.
p.951)

7. Provide oral care  To reduce discomfort

(use of lip balm) of fluid restrictions.
(Source: 12th edition
Nurse’s Pocket Guide,
Doenges,
Moorhouse, Murr,
p.379)

8. Advised NPO  Restriction of sodium

temporarily, low salt aids in decreasing
with SAP as fluid retention
appropriate (Source: 12th edition
Nurse’s Pocket Guide,
Doenges,
Moorhouse, Murr,
p.376)

Dependent:
1. Give Digoxin 0.25  CHF, including that due
mcg 1 tab OD as to venous congestion,
ordered edema
 (Source: 2008 edition
Nurses Drug
Handbook, Sparatto,
Woods p. 456)

2. Insert FBC (Fr- 16)  To monitor urine

and attach to urobag output
as ordered (Source: 14th edition
Nurse’s Pocket Guide,
Doenges,
Moorhouse, Murr,
p.349)
Collaborative:
1. Monitor chest  Reveals changes
xray indicative of increase/
resolution of
pulmonary congestion
(Source: 3rd edition
Nursing Care Plans,
Doenges, Moorhouse,
Geissler p.57)

2. Consult with  May be necessary to

dietitian provide diet acceptable
to patient that meet
caloric needs with
sodium restriction
(ibid.)