Nursing Care Plan

Patient’s Name: L. Fajardo Age: 19 y.o Sex: M Address:

Pathophysiologic/ Nursing
Assessment Cues Nursing Diagnosis Desired Outcome Rationale Evaluation
Schematic Diagram Intervention

Subjective Cues: After 8 hours of Independent After 8 hours of

Decreased Cardiac Predisposing Factors: Nursing Interventions: Nursing
“Nabudlayan ko Output related to an MALE Intervention, the Intervention, the
mag ginhawa kag altered contractility 19 y.o. patient and 1. Assist the patient 1. Allows for better patient and
akon ubo ga balik- as evidenced by significant other in assuming a high chest expansion, significant other
balik 3 na ka pulmonary will be able to: Fowler’s position. thereby improving was able to:
semana” verbalized congestions and Precipitating Factors: pulmonary
by patient cardiomegaly -Heart, kidney and liver Short term capacity.
problems objectives:
- nonadherence to 2. Encourage rest, 2. Physical rest 1. GOAL MET.
Objective Cues: medication 1. Patient will semi-recumbent in should be The patient
- irregular heartbeat Definition: -eating habits report decreased bed or chair. Assist maintained during shows signs of
- fatigue and There is a decrease - Stressful environment episodes of with physical care acute or refractory decrease episode
weakness of blood pumped by dyspnea, angina. as indicated. HF to improve of dyspnea.
- Chest x-ray shows the heart each efficiency of
pulmonary minute because of cardiac contraction 2. GOAL MET.
congestions and the innate ability of Ventricular overload 2. Patient will and to decrease The patient is
cardiomegaly the heart muscle to Decreased ventricular participate in myocardial oxygen participating in
- V/S taken as contract. contraction activities that demand/ the activities as
follows: reduce cardiac consumption and tolerated.
T: 36.8 Ventricular Dilation workload. workload
PR: 79 Source: Myocardial Hypertrophy 3. GOAL MET.
RR: 23 https:// 3. Display vital 3. Monitor V/S, 3. To note response The patient’s
www.rnpedia.com/ Decreased output signs within MIO and daily vital sign is
BP: 130/80 nursing-notes/ acceptable limits, weight and record to activities within acceptable
medical-surgical- dysrhythmias limits.
nursing-notes/ Decreased Renal absent or
congestive-heart- Perfusion controlled, and no 4. Instruct patient
failure-chf/ symptoms of in effective 4. Clears airways
Increased Sodium failure coughing, deep and facilitates
Retention breathing. oxygen delivery.
Long term
Increased Osmotic objectives:
Pressure Dependent
1. Patient’s Interventions: 1. GOAL MET.
Increased ADH respiratory pattern The patient’s
will be effective 1. Administer respiratory
Increased Water without causing supplemental 1. Increases becomes stable.
Reabsorption fatigue oxygen as available oxygen
indicated. for myocardial
Fluid Overload Edema uptake to combat
effects of hypoxia.
S/S
- Signs of left 2. Administer
ventricular failure are prescribed 2. A variety of
evident in the pulmonary medications medications
system (usually a
- Cough, which may combination of a
become productive with diuretic,
frothy sputum an ACEI, or ARB
- Irregular heartbeat and beta blocker)
- Fatigue and weakness may be used to
- Edema on lower increase stroke
extremities volume, improve
- Difficulty of breathing contractility, and
- Cool, clammy skin reduce
congestion

Nursing Diagnosis

Decreased Cardiac
Output related to an
altered contractility