GROUP NAME 4 :

1. Anggi Dwi Agustina

2. Rismawati
3. Syarifah Desnitha
4. Widya Angraini
5. Yulia Fransiska

English
“NURSING CARE PLAN”
 Assessment Diagnosis

Subjective Data:
- The patient says he has a headache
- The patient says chest pain Risk for
-The patient says he is a smoker
Decreased
Cardiac Output
Objective Data:
- respiratory : 15 x/minutes
- pulse: 92 x/minutes
- temperature: 36 C
- blood pressure: 140/90 mmHg
 Goals and Outcomes

Bellow are the common expected outcomes for

decreased cardiac output secondary to
hypertension:
1. Patient will participate in activities that reduce
BP/cardiac workload
2. Patient will maintain BP within individually
acceptable range.
3. Patient will participate in activities that will
prevent stress (stress management balanced
activities and rest plan)
 Nursing
Interventions
- Review client at risk as noted in related
Factors as well as individuals with
conditions that stress the heart.
- Check laboratory data (cardiag complete - To identify contributing factors.
blood cell count, electrolytes,ABGs, blood  
urea nitrogen and creatinine, cardiac
enzymes, and cultures, such as blood,
wound or secretions).
- Monitor and record BP. Measure in both
arms and thights three times, 3-5 min
apart while patient is at rest, then sitting,
then standing for initial evalotuion. Use
correct cuff size and accurate technique.
Rationale
- Persons with acute or chronic conditions
may compromise circulation and place
excessive demands on the heart.
- Comparison of pressures provides a
more complete picture of vascular
involvement or scope of problem. Severe
hypertension is classified in the adult as a
diastolic pressure elevation to 110 mmHg,
progressive diastolic readings above 120
mmHg are

- Not presence, quality of central and
peripheral pulses.
- Auscultate heart tones and breath
sound.
 
considered first accelerated, then
malignant (very severe). Systolic
hypertension also is an established risk
factor for cerebrovascular disease and
ischemic heart disease, when diastolic
pressure is elevated.
- Bounding carotid, jugular, radial, and
femoral pulses may be observed and
palpated. Pulses in the legs and feet may
be diminished, reflecting effects of
vasoconstriction (increased systemic
vascular resistance [SVR]) and venous
congestion.
- S4 heart souds is common in severely
hypertensive patients because of the
presence of atrial hypertrophy (increased
atrial volume and pressure).
 Continue
- Observe skin color, moisture,
temperature, and capillary refill time.
 
- Note dependent and general edema.
- Evaluate client reports or evidence of
extreme fatigue, intolerance for activity,
sudden or progressive shortness of
breath.
Development of s3 indicates ventricular
hypertrophy and impaired functioning.
Presence of crackles, wheezes may
indicate pulmonary congestion secondary
to developing or chronic heart failure.
- Presence of pallor, cool, moist skin, and
delayed capillary refill time may be due to
peripheral vasoconstriction or reflect
cardiac decompensation and decreased
output
- May indicate heart failure, renal or
vascular impairment.
- To assess for signs of poor ventricular
function or impending cardiac failure.
 Continue
THERAPEUTIC INTERVENTIONS : THERAPEUTIC INTERVENTIONS:
Provide calm, restful surroundings, Helps lessen sympathetic stimulation,
minimize environmental activity and noise. promotes relaxation.
Limit the number of visitors and length of
stay.

Maintain activity restrictions (bedrest or Lessens physical stress and tension that
chair rest), schedule periods of affect blood pressure and the course of
uninterrupted rest, assist patient with self- hypertension
care activities as needed.
 

Provide comfort measures (back and neck Decreases discomfort and may reduce
massage, elevation of head). sympathetic stimulation
 

Instruct in relaxation techniques, guided Can reduce stressful stimuli, produce

imagery, distractions calming effect, thereby reducing BP.