Nursing Care Plan (NCP) for a Patient with Congenital Heart Failure

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Subjective: Decreased Short-Term Independent: Short-Term Goal:
“Bakit parang cardiac output Goal:  Placed in a semi-Fowler’s  To decrease oxygen After 8 hours of
sobrang bilis ng related to After 8 hours of position consumption proper nursing
tibok ng puso ko?” altered heart proper nursing interventions, the
as verbalized by the rate interventions, the  Changed position frequently  To avoid the development patient was able to
patient. patient will be able of pressure sores demonstrate
to demonstrate absence of
Objective: absence of  Encouraged to change  To reduce risk for tachycardia.
 Tachycardia tachycardia. positions slowly and dangling orthostatic hypotension
 Confusion of legs before standing Long-Term Goal:
 Cyanosis Long-Term Goal: After 3 days of
After 3 days of  Instructed to elevxated legs  To limit venous stasis and proper nursing
Vital signs: proper nursing when in sitting position improve venous return interventions, the
 HR = 110 bpm interventions, the patient was able to
 BP = 130/90 patient will be able  Provided a quiet environment  To promote adequate rest demonstrate
mmHg to demonstrate increased cardiac
 RR = 25 cpm increased cardiac  Encouraged relaxation  To reduce anxiety and output as evidenced
output. by blood pressure
 Temp. = 36.7 techniques such as deep conserve energy
breathing exercise and pulse within
℃
normal range.
 Assisted with self-care  To maintain adequate rest to
Goal Met.
activities such as taking decrease oxygen
Continue plan.
medications consumption

 Instructed to avoid or limit  To prevent changes in

activities that may stimulate a cardiac pressure and impede
Valsalva response such as blood flow
bearing down during bowel
movement

 Increased activity levels

gradually as permitted by
client or as tolerated  To decreases venous stasis

Collaborative:
 Administered supplemental
O2 via face mask at 3 L per
minute, as indicated  To increase oxygen
 available for cardiac
 Administered digoxin PO function
0.25 mg, as indicated
 To decrease heart rate

References:
Doanges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and
Rationales. (14 ed.). F. A. DAVIS COMPANY, Philadelphia, Pennsylvania
Vera, M. (2020). 18 Heart Failure Nursing Care Plans. https://nurseslabs.com/heart-failure-nursing-care-plans/