DAVAO DOCTORS COLLEGE

General Malvar St., Davao City Nursing Program

NURSING CARE PLAN

Name of Patient: Patient X Date of Admission: November 17, 2023 _ Room: 313 Age: 32 Sex: Male Civil Status: Married
Chief Complaint: Acute onset of shortness of breath. Religion: N/A Attending Physician:

PROBLEM SCIENTIFIC BASIS GOALS/OBJECTIVES NURSING RATIONALE EVALUATION

CRITERIA INTERVENTIONS

Date & Time: Nursing Diagnosis; After 8 hours of nursing INDEPENDENT November 17, 2023
INDEPENDENT
November 17, 2023@; Risk for decreased cardiac intervention, the patient will 1. Establish rapport to @;4:00PM
1. To gain trust and
8:00AM output related to decreased be able to demonstrate: the patient. cooperation of the
preload as evidenced by
patient. “GOAL MET”
Subjective; Increased respiratory rate,  The client 2. Assess heart rate and
“ga lisod man ako hinga” and tachycardia demonstrates rhythm. After 8 hours of nursing
adequate cardiac . intervention, the patient was
Objective; 2. Compensatory
Scientific Basis: output as evidenced by able to demonstrate
tachycardia is a
Temp: 38.9 The cardiac output is often blood pressure and
common response for
measured in liters per pulse rate and rhythm
Respiratory Rate: clients with significantly
minute (L/min). It is crucial to within normal  The client was able to
low blood pressure to
27 bpm note, however, that the parameters for the demonstrates adequate
reduce cardiac output.
typical range might vary client; strong peripheral cardiac output as
Oxygen depending on characteristics pulses; and an ability to
3. Orthostatic hypotension evidenced by blood
saturation: 91% such as age, size, and tolerate activity without 3. Auscultate the blood
is a sustained decrease of pressure and pulse rate
activity level. Elite athletes, symptoms of dyspnea, pressure and note for
Heart Rate: 105bpm and rhythm within normal
for example, have a cardiac syncope, or chest pain. orthostatic hypotension. at least 20 mm Hg in
parameters for the client;
 The client exhibits systolic BP or 10 mm Hg in
Blood Pressure: output of more than 35 L/min diastolic BP within three
strong peripheral pulses;
150/100 mmHg during activity. warm, dry skin, and and an ability to tolerate
eupnea with the minutes of moving from a activity without symptoms
Assessment: absence of pulmonary lying or sitting position. of dyspnea, syncope, or
REFERENCE: crackles. chest pain.
(+) skin and nail beds  The client remains 4. Weak pulses are present
Doenges, M. E., Moorhouse, 4. Check for peripheral  The individual
looks pale free of side effects from in reduced stroke volume
M. F., & Murr, A. C. (2022). pulses. demonstrated warm, dry
(+) cutaneous lesions all Nurse's pocket guide: the medications used to and cardiac output. skin and eupnea in the
over his body with some Diagnoses, prioritized achieve adequate absence of pulmonary
bruising interventions and rationales. cardiac output. 5. Clients who have normal crackles.
5. Assess for jugular vein
F.A. Davis.  The client explains blood volume have visible  The client remains free
pulsations.
(+) nasal flaring the actions and jugular veins while lying in of side effects from the
(+) body malaise precautions to take for a supine position with the medications used to
cardiac disease. head of the bed elevated achieve adequate cardiac
(+)generalized weakness
at 30°. output.
 The client was able to
6. Perform capillary refill 6. Capillary refill is explain the actions and
test (CRT). sometimes slow or precautions to take for
absent. Prolonged cardiac disease.
capillary refill time
indicates inadequate
arterial perfusion to the
extremities.

7. Auscultate heart sounds 7. The new onset of a gallop

for gallops (S3, S4); rhythm, tachycardia, and
auscultate breath fine crackles in lung bases
sounds. can indicate the onset of
8. Monitor urine output. If heart failure.
the client is acutely ill, 8. Urine output is an
measure hourly urine important indicator of
output and note a cardiac function. Reduced
decrease in output. cardiac output results in
9. Assess for reports of reduced perfusion of the
fatigue and reduced kidneys, with a resulting
activity tolerance. decrease in urine output.
10. Place the client in a 9. Fatigue and exertional
comfortable position dyspnea are common
that facilitates problems with low
breathing. cardiac output states.
11. Maintain adequate 10. The client may be
ventilation and positioned or taught how
perfusion through to assume a position that
proper positioning of facilitates breathing.
the client. 11. Position client in semi-
Fowler to high-Fowler. An
upright position is
recommended to reduce
preload and ventricular
filling when fluid overload
is the cause.
 DEPENDENT DEPENDENT
1. Administer medications as 1. To promote comfort and to
ordered by the physician. lessen the presence of pain.

BBN/DTS/2023
JHON KRISTOPHER C. BERNADAS NAME
OF STUDENT