Assessment Diagnosis Scientific Goal Intervention Rationale Expected

Explanation Outcome

SUBJECTIVE: Cardiac Disruption of After 1 hour • Monitor VS including • Indicates change in cardiac The patient
Output, cardiac of nursing apical pulse, peripheral status and potential for will be able to
0 decreased r/t functioning intervention pulses and capillary refill. arrhythmias. have near to
result in
altered the patient normal V/S
problem • Describe heart sounds (S3, • Indication of reduced
myocardial associated with will display and participate
OBJECTIVE: contractility vital signs S4) and breath sounds cardiac output by mechanical in activities
feeling ties of
near to (Crackles,wheezes). failure, pulmonary edema. that reduce
the
•Cool, pale and
atrium/ventricle normal and cardiac
clammy skin. s. Compromise lessen the workload.
filling times or symptoms of •Monitor electrolyte level of •Diuretic therapy may induce
• Body malaise
an altered heart Na increases and K hypokalemia, decreased GFR
failure.
•Crackles rate will
decreases. may cause hypernatremia;
decrease stroke
volume thereby arriythmias may be induced
Tachycardia
decreasing by Potassium imbalances.
 Weak and cardiac output. • Monitor urine output,
Increase preload •Kidney respond to reduced
thready pulse noting decreasing output and cardiac output by retaining
usually
dark or concentrated urine. water and sodium
•Orthopnea increases
contractility and • Provide comfortable quiet
stretch because •Psychological rest help
• Cold environment limiting stimuli.
of filling reduce emotional stress,
extremities
pressure from which can produce
• Edema in venous return vasoconstriction, elevating
and previous
extremities BP and increasing heart rate
volume. Stretch
and filling or work.
• Urine output •Provide bed rest with head
pressure may elevated 30-60 degrees. •Promotes lung expansion
rise beyond the
Pitting edema: capabilities of and decreases venous return.
the normally
Grade 3 compliant heart. •Perform deep breathing •Improves breathing and
These increased exercises, incentive oxygen intake.
preload lessens spirometry every 2 hours.
the force and •Reduces pressure on
efficiency of •Instruct the patient to have diaphragm and enhances
ventricular small meals. chest expansion.
• V/S taken as contraction.
follows •Administer inotropic agent •Increases cardiac output by
(digoxin) as prescribed while increasing cardiac
T: 36.2 ˚C
monitoring hemodynamic contractility.
P: 88 bpm status.
• Increases available oxygen
R: 26 bpm •Administer supplemental for myocardial uptake to
oxygen as indicated. combat effects of hypoxia or
ischemia.

•Diuretics, in conjunction
•Administer diuretics with restriction of dietary
(furosemide) as prescribed. sodium and fluids, often lead
to clinical improvement in
patients with heart failure.
•Report palpitations,
dizziness, weakness, fatigue, •Side effects of hypokalemia
leg cramps and excessive from diuretic.
thirst.
•May interact with
•Avoid OTC drugs without prescribed medications.
consulting physician.
Assessment Diagnosis Scientific Goal Intervention Rationale Expected
 Explanation Outcome

Subjective: Fluid volume Individual After 1 hour >Monitor and >Results from The patient
patient willbe
“lumaki tyan ko excess related with cardiac able to record diuretic therapy and participated
at mga paa ko” to problems participate and electrolytes, sodium retention. and apply
as verbalized by compromised frequently understand the hypokalemia and health
the patient. regulatory have difficulty interventions and hypernatremia teachings. The
mechanism of with fluid health teachings for >Acts on distal signs and
decreased balance. The fluid volume excess. >Administer tubule and increases symptoms of
glomerular greater the Diuretic as water , K excretion fluid volume
Objective: filtration fluid volume, indicated excess shows
resulting in the greater the >Potential for fluid gradually
>Weakness sodium and stress and > Administer IV over load with subsides.
> fatigue fluid retention cardiac therapy as decrease GFR
> Pallor
>diaphoretic workload. indicated
>distended Compromised
jugular vein cardiac
>presence of functioning >Teach patient to >Sodium limitation
Dysrhythmias
>with ascitis causes fluids restrict sodium caused by inability
Abdominal to accumulate diet and explain of the kidneys to
girth: 39 in various the rationale eliminate it.
inches body tissues.
>Urine
output: These fluid
_____/hour overload >teach patient to >Foods containing K
>with edema in stresses the include citrus to replace losses
legs and feet circulatory juices, banana,
>capillary refill system and whole grains,
on feet: 4 increases the apple, broth
seconds workload of
> BP: the heart. >Measure fluid >Provides accurate
>weight: I and O and using intake when fluids
same container limited.
with equal
 amounts
whenever
drinking fluids
add totaling at
end of the day
spread intake
over 24 hours and
suggest rinsing
mouth and
sucking on hard
candy to reduce
thirst.

Assessment Diagnosis Scientific Goal Intervention Rationale Expected

 Explanation Outcome
S>”Laging Fatigue It results After 1 hour > Encourage alternate >This avoids extended Fatigue reduced
pagod ang related to from the low the patient rest and activity periods of either activity and energy level
pakiramdam ko” circulation cardiac will be able periods. or exercise. and endurance
as verbalized by causing poor output that to verbalize increased,
the patient. oxygenation deprives a >Assist the client to > Rest periods should ability to engage
of tissues tissues of measurable schedule rest periods help restore client in tolerable level
O>body normal increase in and avoid care energy levels. of ADL.
weakness circulation activity activities during
and tolerance. scheduled rest periods.
>Pale
decreases > Arrange Physical >Arranging physical
>Moving at the removal activities (e.g., avoid activities reduces
slow pace of catabolic activity immediately competition for oxygen
waste after meals). supply to vital body
>dark shadows functions.
products. It
under the eye
may also
result of the
>palpitations increase
energy > Instruct the client or
>yawning
expended significant other to > Symptoms of undue
> inability to for breathing recognize the signs and fatigue require a
concentrate and the symptoms of fatigue. reduction in activity.
insomnia
that results
>V/S from
BP: 140/90 respiratory
distress and
RR: 26 coughing.
 Assessment Diagnosis Scientific Goal Intervention Rationale Expected
Explanation Outcome
S> Impaired gas Pulmonary After 15 minutes Independent decrease
“Nahihirapan exchange congestion of of nursing dyspnea and
ako huminga” related to fluid predominates interventions, >Encourage >This will help decrease
as verbalized in the alveoli when the left the patient will client to turn, facilitate pulmonary
by the patient. ventricle fails, improve gas cough and oxygen congestion,
because the left exchange deep breath delivery and respiratory rate
ventricle is evidenced by clear the is normal
enable to decrease airways
O>weak
adequately dyspnea and >Administer
>Irritable pump the blood decrease oxygen as
coming to it from pulmonary ordered >Oxygen
>uncomfortabl the lungs. The congestion upon therapy will
e inc.pressure in auscultation improve
the pulmonary oxygenation
>hyperventilat
circulation by increase
ion
causes fluid to the amount of
>with crackles be forced into oxygen.
the pulmonary
>dyspnea tissues.
Dyspnea result >Position the
>weak from the client to >Fowler
thready pulse accumulation of facilitate position and
fluid in the breathing and orthopneic
V/S: observe for positioning
alveoli, which
impares gas paroxysmal facilitates
RR: 26 bpm
exchange. and no diaphragmatic
dyspnea excursion.

>Obtain >Arterial
arterial blood blood gasses
gasses if indicate
ordered whether the
patient has
hypoxia, and
Collaborative acidosis or
both
>Administer
diuretic >Diuretics
therapy as promote fluid
ordered and flow in the
monitor for alveoli as well
effectiveness as
systematically.