Cues Nursing Background Goals of Care Intervention Rationale Evaluation

Diagnosis Knowledge

Subjective: Decreased Decreased The purpose is to Independent: 1. Reduced GOAL MET

Patient cardiac Ventricular show 1. Placed the oxygen
output
complain in contraction hemodynamic patient in semi consumption 1. The patient's
related to
increased stability in areas fowler’s position, and vital signs should
altered
urinary afterload such as blood and may elevates decompression be normal after 8
frequency and Ventricular pressure, cardiac legs 20-30 degrees danger. hours of nurse
contractilit Overload output, renal in shock situation. care.
Objectives: y of the perfusion/urine 2. to keep track
BP: heart output, and 2. Monitor Vital of response 2. A well-
secondary
104/54mmH Altered ability peripheral pulses. signs activities/interve established and
to
g congestive to pump ntions efficient breathing
failure enough OBJECTIVE: 3. Monitor cardiac pattern.
PR: 74bpm oxygenated After 8 hours of rhythm 3. To assess the
blood to meet nursing continuously efficacy of 3. The patient
RR: 24cpm the body’s interventions, the medicines reported fewer
BMI: 40.2 metabolic patient will be 4. Assess urine and/or episodes of
(extremely requirements able : output hourly or supportive dyspnea and
obese) periodically and equipment such angina.
a. Report / weight the client as an implanted
Increased demonstrate a daily noting total pacemaker.
heart rate, decrease in fluid balance
vasoconstricti dyspnea, angina, 4.to enable for
on , and and dysarrythmia 5. Monitor rate of rapid changes to
hyperthropy occurrences. IV drugs closely the therapy
,using infusion regimen
b. Show an pumps as
Decreased increase in appropriate 5. To avoid
cardiac output exercise bolus/overdose.
tolerance. 6. provide quiet
and comfortable 6. To encourage
c Knowledge of environment proper rest.
the illness
process, individual 7. Assist with 7. Restricting
risk factors, and perform self-care activities that
treatment activities for client reduce oxygen
strategy utilization.
expressed 8. Provide
verbally. information about 8. Encourage
testing procedures client
d. Participate in and dietary compliance with
activities that will /fluid restrictions the treatment
reduce your regimen.
workload. 9. Provide
psychological 9. When the
support. Maintain customer is
a calm attitude but aware of so
admit concerns if many activities
questioned by and concerns,
client. honesty may be
reassuring.
Dependent:
1.To increase
1.Administer oxygen available
oxygen via nasal for cardiac
cannula or mask function and
Indicated tissue perfusion

2.Administer fluid 2.To prevent or

replacement, alleviate the
antibiotics and/or symptoms of
diuretics as fluid retention
indicated
3. To promote
3. Administer comfort/rest.
analgesics