Name of Patient: S.

C Civil Status: Married

Diagnosis: Risk for Decreased Cardiac Output Age: 25 years old Sex: Female

ASSESSMENT NURSING DIAGNOSIS PLAN INTERVENTIONS RATIONALE EVALUATION

(Differentiate (Actual or Potential (Include Long and (At least 5 and include (with scientific (State whether met,
OBJECTIVE from with complete parts) Short Term Goals only the MOST evidences as needed) partially met or
SUBJECTIVE DATA) plus at least 3 APPROPRIATE for unmet and the
outcome criteria) client’s context) supporting
outcomes)
SUBJECTIVE: Decreased Cardiac SHORT TERM SHORT TERM
N/A Output Pregnancy
related to Pregnancy After 8 hours of nursing -Evaluate client reports or -To assess for signs of After 8 hours of nursing
Induced Hypertension intervention: evidence of poor ventricular function or intervention, goal was
OBJECTIVE: extreme fatigue, impending cardiac failure. met:
intolerance for activity,
The blood pressure  The patient will sudden or progressive  The patient was
ranging 130/90 verbalize the weight gain, swelling of able verbalize the
understanding of the understanding of
extremities, and
disease, process the disease,
progressive shortness of
lowering decrease - Helps lessen process on lowering
blood pressure and breath. sympathetic stimulation; blood pressure and
the treatment promotes relaxation. the treatment
regimen -Provide calm, restful regimen
surroundings, minimize
environmental activity and
 Blood pressure within noise. -Provides understanding  Span of care of
the normal range. elevation of BP and client did not
clarifies misconceptions experienced
also understanding BP can further
exist without symptoms or complications
 - Define the state and even when feeling well.
limits of BP. Explain brought about the
Hypertension and it affects decreased of
blood vessels and brain. cardiac output the
-Decreases discomfort goal has met the
and may reduce blood pressure
sympathetic stimulation. range within
normal
LONG TERM -Provide comfort measures - Persons with acute or
(back and neck massage, chronic conditions may
After 5 days of nursing elevation of head). compromise circulation LONG TERM
intervention: and place excessive After 5 days of
-Review clients at risk as demands on the heart. intervention
The client will maintain noted in Related Factors
adequate cardiac output as well as individuals with
and cardiac index conditions that stress the The client will maintain
heart. -Provides relaxation adequate cardiac output
and cardiac index goal
was met.
-Provides a clean
environment minimizing
noise, limiting visitors and -Decreases peripheral
length of stay. venous pooling that may
be potentiated by
- Suggest frequent vasodilators.
position changes, leg
exercises when laying
down