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Cardiovascular Disease NCP
Cardiovascular Disease NCP
Manguiat 11/15/2021
3 BSN-B / NCM 112 PROF. HERMAN ZOLETA
NURSING CARE PLAN
CARDIOVASCULAR DISEASES
HEART FAILURE
PLANNING
ASSESSMENT NURSING GOAL/ NURSING RATIONALE EVALUATION
DIAGNOSIS EXPECTED INTERVENTION
OUTCOME
Objectives: Decreased Short Term Goal: 1. Assess heart 1. Peripheral pulses Goal is
cardiac output sounds, VS, peripheral and capillary refills partially met,
pulses, capillary refill. may be weak with
heart murmurs related to 1. Patient will be
reduced stroke
as auscultated chronic heart free from crackles Patient able to
volume and cardiac
failure in lungs by output. cough up
decreased secondary to adequately 2. Assess for breath secretions
activity rheumatic coughing up sounds. 2. Crackles reflect adequately.
intolerance heart disease secretions during accumulation of fluid Pulmonary
as evidenced the shift. in pulmonary crackles not
circulation. auscultated in
fatigue by heart
3. Assess the weight,
murmurs, 2. Patient will get bases of
skin color and 3. Weight is an
decreased decreased out of bed at least temperature, urinary indication of fluid lungs. Patient
urinary output activity 3x as tolerated output. retention. is also
intolerance during the shift. responding
dyspnea and 4. Monitor serum well from the
crackles Long Term Goal: electrolytes and 4. Hyponatremia and medications
digitalis level. hypochlorite are and waiting
causative factors for
1. After surgery, for the
diuretic use.
patient maintains 5. Administer surgery.
adequate cardiac ampicillin-sulbactam, 5. Ampicillin for
output as evidence captopril, pneumonia. Captopril
by strong chlorothiazide, for reducing BP and
digoxin, furosemide. decreasing workload
peripheral pulses,
(as prescribe by the of heart.
BP within normal physician) Chlorothiazide and
range for age, furosemide to reduce
urinary output >30 circulating volume,
ml/hr, warm and enhance sodium and
dry skin, eupnea water excretion, and
with absence of improve symptoms.
Digoxin to improve
pulmonary
myocardial
crackles by contractility.
discharge
6. Encourage low salt
intake.
8. Start patient on
ferrous sulfate as
prescribed by the
physician. Hgb 10.5
g/dL and Hct 33.6%.
PLANNING
ASSESSMEN NURSING GOAL/ NURSING RATIONALE EVALUATION
T DIAGNOSIS EXPECTED INTERVENTION
OUTCOME
6. Teach patient 6. HR is a
to self-monitor guide for
their pulse rate if monitoring
appropriate. intensity or
duration of
exercise.
PLANNING
ASSESSMEN NURSING GOAL/ NURSING RATIONALE EVALUATION
T DIAGNOSIS EXPECTED INTERVENTION
OUTCOME
8. Position
patient in optimal
body alignment
in semi- fowler’s
position for
breathing.
PLANNING
ASSESSMEN NURSING GOAL/ NURSING RATIONALE EVALUATION
T DIAGNOSIS EXPECTED INTERVENTION
OUTCOME
6. Administer 6. It improves,
oxygen therapy oxygen is
as ordered. titrated to
maintain pulse
oximetry
readings greater
than 92%.
7. Administer 7. Diuretics
diuretics as promote
ordered. normovolemia
by decreasing
fluid
accumulation
and blood
volume.