Cues: Background Nursing Goal/

of the diagnosis
Subjective/ Objectives Intervention Rationale Evaluation
disease
Objective
S- Decreased Decreased Goal Independent: Goal partially
“nanghihina ventricular cardiac To demonstrate 1. Place patient in semi- -decreases oxygen met
nga ako at contraction output hemodynamic fowler’s position, and consumption and
medyo related to stability including may elevate legs 20-30 risk of After 8 hours
nahihirapang Ventricular altered blood pressure, degrees in shock decompression. of nursing
huminga,” as overload afterload cardiac output, situation interventions
verbalized by and renal 2. Monitor vital signs -to note response the patient
the patient. Altered ability contractility perfusion/urine to activities/ was able
to pump of the heart output, and interventions report
O- difficulty of enough secondary peripheral 3. Monitor cardiac rhythm -to note decrease
breathing oxygenated to pulses. continuously effectiveness of episodes of
-orthopnea blood to meet congestive medications and/or dyspnea, and
-edema on the body’s heart failure Objectives assistive devices angina.
both feet metabolic After 8 hours of like implanted Dysarythmias
-decreased requirements nursing pacemaker were still
peripheral interventions, evident when
pulse increased the patient will 4. Assess urine output -to allow for timely auscultated.
-crackles heart rate, be able: hourly or periodically alterations on The patient
Vital signs: vasoconstricti a. Report/ and weigh the client therapeutic had an
RR -24 cpm on, and demonstrate daily noting total fluid regimen increase on
HR -121 bpm hypertrophy decrease balance activity
 episodes of 5. Monitor rate of IV drugs -to prevent tolerance and
decreased dyspnea, closely, using infusion bolus/overdose participates in
cardiac angina and pumps as appropriate activities that
output dysarythmia 6. Provide quiet and -to promote reduce
b. Demonstrate comfortable adequate rest. cardiac
an increase in environment workload.
activity 7. Assist with or perform -to limit activities RR – 22 cpm
tolerance self-care activities for that will decrease HR – 112 bpm
c.Verbalize client oxygen
knowledge of consumption
the disease 8. Provide information -to promote client
process, about testing participation on the
individual risk procedures and therapeutic
factors and dietary/fluid restrictions regimen
treatment plan 9. Provide psychological -honesty can be
d. Participate in support. Maintain a reassuring when so
activities that calm attitude but admit much activities and
reduce concerns if questioned worry are apparent
workload of by client to the client.
the heart.
Dependent:
1. Administer oxygen via -to increase oxygen
nasal cannula or mask available for
as indicated cardiac function
 and tissue
perfusion
2. Administer fluid -to prevent or
replacement, antibiotics alleviate the
and/or diuretics as symptoms of fluid
indicated retention

3. Administer analgesics -to promote

comfort/rest