Rank 1

Identified Cues PRIORITIZATION Problem Decrease Subjective: cardiac The son of the client verbalized the output following: related to heart - Minsan nanginginig si tatay tapos failure nilalamig at hirap na din siyang magsalita. May nararamdaman din siyang hilo. -Nahihirapan din siyang huminga at parang may kabog sa kaniyang dibdib.

Justification

Heart failure is a physiologic state in which the heart cannot pump to meet to meet the metabolic needs of the body as determined by oxygen consumption by Joyce Black. According to Maslows hierarchy of needs, oxygen is [part of physiologic needs that is vital for human survival and must be given prompt interventions. It is the prioritized - Mukha ring matamlay si tatay na parang problem because a decreased cardiac may dinadalang problema. output can result to several effects such as chest pain, skin pallor, Objective: hypotension, diaphoresis, nausea, agitation and a decrease of level of -dysrrythmia consciousness and more adverse -bradycardia effects such as ineffective tissue -jugular vein distention perfusion, coronary artery disease, -generalized edema accompanied with pain ischemia and eventually death. If this problem will be managed -cold clammy skin accordingly, it will alleviate the -prolonged capillary refill clients situation and it will improve -decrease peripheral pulse (49 bpm) her condition. Thus, resolving this -variations in blood pressure reading problem will result to the solution of BP: 100/70 mmHg, 80/60 mmHg other identified problem. In -presence of crackles and wheezing sound addition, it is a geriatric case so -oliguria: 60 ml of urine with presence of vulnerability of the client should also blood tinge for 8 hours be considered. -paleness -orthopnea 38cpm - presence of S3 sound -restlessness -weakness -body malaise -dry buccal mucosa -dry skin folds -dry pale lips Excess -generalized edema accompanied with pain It is the second problem to be fluid -orthopnea 38cpm prioritized because it affects the volume -oliguria: 60 ml of urine with presence of blood circulation within the body related to blood tinge for 8 hours which is an effect of heart failure decrease -crackles causing decreased cardiac output. cardiac -Dyspnea Fluid accumulation suggests poor output -RR= 38cpm circulation. Therefore, cardiac output should be corrected in order to increase circulation. Impaired -crackles It is the third problem to be gas -pallor prioritized because alveoli fluid exchange -Dyspnea filling is secondary to decreased