NURSING CARE PLAN

ASSESSMENT NSG. SCIENTIFIC PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS ANALYSIS
SUBJECTIVE DATA: Ineffective After 4 hours of Nursing Establish rapport To gain comfort feelings form After the 4 hours of Nursing
The patient verbalized breathing intervention, Patient’s the patient and significant Intervention, Patient’s
that " nahihirapan akong pattern respiratory pattern will be others, respiratory pattern will
huminga at masakit ung related to effective without causing effective without causing
dibdib ko parang may fatigue and fatigue Monitor and record vital To gain baseline data fatigue
tumutusok papunta sa decreased signs
likod ko" lung For symmetry of respiratory
OBJECTIVE DATA: expansion Inspect thorax movement
Weakness and
Patient using accessory pulmonary Determines adequacy of Identifies increased work of
muscle when breathing congestion breathing breathing
Chest pain radiating secondary to Observe breathing pattern
towards her back (9/10) CHF for SOB, nasal flaring,
Pursed lip breathing pursed-lip breathing or
Tachypnea prolonged expiratory
phase and use of
accessory muscles
Vital signs:
BP-180/110mmhg Therapeutic Interventions
PR-95bpm Measure tidal volume and
RR- 28cpm vital capacity Indicates volume of air moving
in and out of lungs
Assess emotional
response
Detects use of
hyperventilation as a
causative factor
 Position patient in optimal
body alignment in semi-
fowler’s position for
breathing. Assist patient Reduces muscle tension,
to use relaxation decreases work of breathing
techniques.

NURSING CARE PLAN

ASSESSMENT NSG. SCIENTIFIC PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS ANALYSIS
SUBJECTIVE DATA: Decreased After 8hours of Nursing 1. Auscultate apical pulse, - Tachycardia is usually After the 8hours of
The patient verbalized cardiac output intervention, the patient assess heart rate, rhythm. present (even at rest) to Nursing Intervention, goal
that " nahihirapan related to will able to: Document dysrhythmia if compensate for decreased was met AEB:
akong huminga at altered telemetry is available. ventricular contractility. - Patient
masakit ung dibdib ko myocardial - Patient will Note: Intractable Premature atrial demonstrated
parang may tumutusok contractility/in demonstrate ventricular dysrhythmias contractions (PACs), adequate cardiac
papunta sa likod ko at otropic adequate cardiac unresponsive to paroxysmal atrial output as
dipa ako umiihi mula changes as output as medication suggest tachycardia (PAT), PVCs, evidenced by vital
kagabi hanggang evidence by evidenced by vital ventricular aneurysm multifocal atrial signs within
ngayon" increases blood signs within tachycardia (MAT), and acceptable limits,
OBJECTIVE DATA: pressure and acceptable limits, atrial fibrillation (AF) are dysrhythmias
Patient using accessory respiratory rate dysrhythmias common dysrhythmias absent/controlled,
muscle when breathing absent/controlled, associated with HF, and no symptoms
Chest pain radiating and no symptoms although others may also of failure (e.g.,
towards her back of failure (e.g., occur. hemodynamic
(9/10) hemodynamic parameters within
Decreased urine parameters within 2. Monitor BP. - In early, moderate, or acceptable limits,
output acceptable limits, chronic HF, BP may be urinary output
urinary output elevated because of adequate).
Vital signs: adequate). increased SVR. In
BP-180/110mmhg advanced HF, the body - Patient reported
PR-95bpm - Patient will report may no longer be able to decreased
RR- 28cpm decreased compensate, and episodes of
episodes of profound hypotension dyspnea, angina.
dyspnea, angina. may occur
o Patient - Patient
will 3. Monitor urine output, - Kidneys respond to participated in
participat noting decreasing output reduced cardiac output by activities that
e in and concentrated urine. retaining water and reduce cardiac
activities sodium. Urine output is workload.
that usually decreased during
the day because of fluid
reduce shifts into tissues but may
cardiac be increased at night
workload. because fluid returns to
circulation when patient is
recumbent.

- Makes more oxygen

4. Give oxygen as
indicated by patient
symptoms, oxygen
saturation and ABGs.
available for gas
exchange, assisting to
alleviate signs of hypoxia
and subsequent activity
intolerance

- Decreases the risk for

development of cardiac
5. Implement strategies to output due to imbalances.
treat fluid and electrolyte
imbalances

- Diuretics, in conjunction
6. Administer medication
as prescribed by the
doctor like
Diuretics: furosemide
(Lasix), ethacrynic acid
(Edecrin), bumetanide
(Bumex), spironolactone
(Aldactone).Beta-
adrenergic receptor
with restriction of dietary
sodium and fluids, often
lead to clinical
improvement in patients
with stages I and II HF. In
general, type and dosage
of diuretic depend on
cause and degree of HF
and state of renal
function. Preload
reduction is most useful in
antagonists: carvedilol
(Coreg), bisoprolol
(Zebeta), metoprolol
(Lopressor).
- Because of existing
7. Administer IV solutions,
restricting total amount as
indicated. Avoid saline
solutions.
treating patients with a
relatively normal cardiac
output accompanied by
congestive symptoms.
Loop diuretics block
chloride reabsorption,
thus interfering with the
reabsorption of sodium
and water. While beta-
blockers is useful in the
treatment of HF by
blocking the cardiac
effects of chronic
adrenergic stimulation.
Many patients
experience improved
activity tolerance and
ejection fraction.
elevated left ventricular
pressure, patient may not
tolerate increased fluid
volume (preload). Patients
with HF also excrete less
sodium, which causes fluid
retention and increases
myocardial workload.
NURSING CARE PLAN
ASSESSMENT NSG. SCIENTIFIC PLANNING IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS ANALYSIS
SUBJECTIVE DATA: ACTIVITY After 8hours of Nursing 1. Check vital signs before Orthostatic hypotension can After the 8hours of Nursing
The patient verbalized INTOLERANCE intervention, the patient and immediately after occur with activity because of Intervention, The client:
that "hindi ako nag RELATED TO will able to: activity, especially if medication effect - Participated in
eehersisyo dahil IMBALANCE patient is receiving (vasodilation), fluid shifts desired activities;
mabilis ako mapagod BETWEEN - Participate in vasodilators, diuretics, or (diuresis), or compromised meet own self-care
at nahihirapan ako OXYGEN desired activities; beta-blockers cardiac pumping function needs.
huminga" SUPPLY/DEMA meet own self-
ND care needs. 2. Document Compromised myocardium - Achieved measurable
OBJECTIVE DATA: cardiopulmonary response and/or inability to increase increase in activity
Changes in Vital signs - Achieve to activity. Note stroke volume during activity tolerance, evidenced
Weakness measurable tachycardia, dysrhythmias, may cause an immediate by reduced fatigue
Fatigue increase in activity dyspnea, diaphoresis, increase in heart rate and and weakness and by
Dyspnea tolerance, pallor. oxygen demands, thereby vital signs within
Obese evidenced by aggravating weakness and acceptable limits
reduced fatigue fatigue during activity.
and weakness and
by vital signs Fatigue is a side effect of some
within acceptable 3. Assess for other causes medications (beta-blockers,
limits during of fatigue (treatments, tranquilizers, and sedatives).
activity. pain, medications) Pain and stressful regimens
also extract energy and
produce fatigue.

Meets patient’s personal care

4. Provide assistance with
self-care activities as
indicated. Intersperse
activity periods with rest
periods
needs without undue
myocardial stress and excessive
oxygen demand.

5. Assist patient with To prevent deep vein

ROM exercises. Check thrombosis due to vascular
regularly for calf pain and congestion
tenderness.

6. Elevate the head of the Maintains an open airway

bed

7. Assist the client in Prevents risk for falls that could

ambulation lead to injury