Assessment

Nursing Diagnosis ScientiIic Explanation Planning Implementation Rationale Evaluation

Subjective:
' Di siya
makahinga, uumiyak
ng malakas at
papitik pitik ang
mga paa at kamay
niya.. as verbalized
by the client`s Iather



Objective:
- clubbing Iingers
-cyanosis
-capillary reIill oI
more than 6 seconds

IneIIective tissue
perIusion related to
interruption oI blood
Ilow as evidenced
by capillary reIill oI
more than 3 second


underdevelopment oI
the right
ventricular inIudibulum


right ventricular
hyperthrophy


obstruction


high pressure
in the right ventricle


leIt shunt
oI blood through VSD


cyanosis, clubbing

ReIerence: Med-
Surgery, Brunner

Discharge outcome:
The day prior to
discharge the client
will be able to
improve/increase
tissue perIusion


Short term outcome:
AIter a week oI
nursing intervention,
the client will be
able to:
* understand the
present condition
* demonstrate
liIestyle changes to
improve circulation



- note
presence/degree oI
dyspnea, cyanosis,
hemoptysis

- review baseline oI
ABG, electrolytes,
BUN/Cr, cardiac
enzymes

- monitor VS ,
hemodynamics,
heart sound and
cardiac rhythm

- encourage quiet,
restIul atmosphere


-place In knee chest
position

- caution client to
avoid activities that
increase cardiac
work load

- Demonstrate
relaxation techniques


- to note degree oI
impairment/organ
involvement


- serve as a baseline
comparison aIter
treatment


- to determine the
level oI body
Iunction related to
the disease

- Conserves
energy/lowers tissue
O2 demand

- to trap blood in to
the lower extremities

-prevent O2 demand




- to decrease tension
level


Discharge outcome:
Outcome achieved
The day prior to
discharge the client
was able to
improve/increase
tissue perIusion


Short term outcome:
Outcome achieved
AIter a week oI
nursing intervention,
the client was able
to:
* understand the
present condition
* demonstrate
liIestyle changes to
improve circulation

Collaborative:
- administer O2
therapy as prescribed

-administer
prescribed
medication
(Propanolol)

- assist in temporary
or palliative surgery
(Blalock-Taussig)


- to maximize tissue
perIusion

- to aid pulmonary
artery dilation



- Ior treatment or
reduce symptoms oI
the underlying
disease


ReIerence: Maternal
and child nursing,
Pilliteri