NURSING CARE PLAN

CUES NURSING EXPECTED NURSING RATIONALE EVALUATION DISCHARGE

DIAGNOSIS OUTCOME INTERVENTIO PLANNING
N
Subjective Cue/s: Impaired gas After 30 minutes of Independent: MET. Patient Medications:
 Shortness exchange intervention, patient -To is for Furosemide
of breath related to will be able to: 1. Establish communicate discharge. 20mg/ tablet 1
and fatigue alveolar- rapport. and gather data tablet once a
capillary a. verbalize relief well. Partially Met. day- 6am
“daw gina lagas ko membrane from shortness of Crackles on L
akon pagginhawa changes as breath 2. Monitor - For baseline lower Spironolactone
kag dasig ako manifested patient’s vitals information decreased 25mg/ tablet 1
makapoy.” by shortness b. maintain normal signs and tablet once a
of breath, oxygen saturation weight. Unmet. Patient day- 2pm
Objective Cue/s: fatigue, died.
 Edema on edema on 3. Assess - For baseline Lisinopril
both legs both legs patient’s current data. The 10mg/ tablet 1
(1+) (1+), status. To presence of tablet once a
 Increased increased include crackles and day
blood blood auscultation of wheezes may
pressure pressure lung fields signal airway Environment:
(152/106 152/106 obstruction Provide safe
mmHg) mmHg, and secure
 Sudden sudden 4. Place patient - To facilitate environment
weight gain weight gain on high fowler’s relaxing of outside the
(from 75kg- (75kg-78kg), position or high tension of hospital.
78kg) crackles on back rest abdominal
 Crackles on left lower muscles which Treatment:
L lower lung lung, (+) will help Monitor blood
 Chest X- pleural improve pressure at
Ray PA effusion upon breathing and home
view: chest xray, lower blood
Pleural dilated left After 4 hours to 1 pressure Take
Effusion L atrium, week of nursing medications as
 2D echo: concentric intervention, the 5. Observe for -Cyanosis may prescribed
dilated left left patient will be to: cyanosis of the suggest poor
 atrium, ventricular skin tissue perfusion Health
concentric hypertrophy, a. achieve normal or decreased Education:
left doppler blood pressure bloodflow. When taking
ventricular evidence of diuretics,
hypertrophy relaxation b. return to his 6. Watch for monitor your
, doppler abnormality previous weight signs of If patient is serum
evidence of during 2d psychological psychologically potassium
relaxation echo, c. exhibit normal distress, like distressed, he levels
abnormality decreased breath sounds anxiety, might not
 CBC: hemoglobin, agitation and cooperate with Eat potassium-
decreased abnormal d. regain his insomnia the treatment rich food
hemoglobin ABG previous energy
(10g/dL) (respiratory When
 ABG: acidosis) shortness of
Respiratory Dependent: breath occurs,
Acidosis Specific/sustainable elevate head of
Measurable 1. Administer -To correct and bed to 90
Attainable humidified prevent degrees
Realistic oxygen via alveolar/ tissue
Time-bound nasal cannula or hypoxia Before taking
face mask Furosemide or
Lisinopril,
2. Administer To promote check your
diuretics, such normovolemia blood pressure
as Furosemide by reducing 1st.
and fluid
spironolactone accumulation Outpatient:
as prescribed. and blood Clinic follow up
volume. will be on
February 18,
2021 at Dr. X’s
clinic. You may
3. Monitor Common side call 320.09 09
Potassium effect of Local 5000
levels Diuretics, such
as potassium is Diet:
 hypokalemia Low fat, low
salt and iron
and potassium
4. Administer ACE inhibitors rich food, such
vasodilators, reduce as spinach,
such as angiotensin II bananas,
Lisinopril (ACE and lower avocadoes and
inhibitors), aldosterone so on.
Metropolol (beta secretion. They
blocker) decrease Support
preload and System:
afterload, Encourage
reducing the support from
work of the left family and
ventricle. friends.

5. Administer To help Spirituality

Ferrous Sulfate increase Encourage Mr.
as prescribed. patient’s Ocampo to
hemoglobin seek spiritual
support
system.
6. Standby Patients with
emergency severely
equipment or decompensated
emergency cart heart failure
may suffer
cardiac arrest.

Collaborative
Care:
1. Inform
Department of Iron rich food
Dietary to can help
prepare low fat, increase
low salt, iron- patient’s
rich food for the hemoglobin
patient.

2. Collaborate
with Laboratory To ensure that
Department blood specimen
regarding is collected.
patient serum
Potassium
Monitoring