NURSING CARE PLAN

CUES Subjective cues: Maglisod kog ginhawa kung maghigda, as verbalized by the pt. NURSING DIAGNOSIS Decreased Cardiac Output r/t related to mechanical alteration in preload resulting in ventricular hypertrophy causing a decreased in contractility due to Congestive Heart Failure OBJECTIVES Short term objective: Within 8 hours of rendering nursing care, the patient will be able to verbalize knowledge of the disease process, individual risk factors and treatment plan. INTERVENTIONS 1. Assess urine output hourly. 2. Determine vital signs or hemodynamic parameters including cognitive status. Note vital signs response to activity or procedure and time required to return to baseline. 3. Review diagnostic studies. 4. Evaluate clients reports or evidence of intolerance for activity, sudden or progressive wright gain, swelling of extremities and progressive shortness of breath. 5. Keep client on semi-Fowlers position. 6. Monitor vital signs frequently. 7. Monitor cardiac output. 8. Restrict or administer fluids RATIONALE 1. To allow for timely alteration and therapeutic regimen. 2. Provides baseline for comparison to follow trends and evaluate response to interventions. 3. Helps determine underlying cause. 4. To assess for signs of poor ventricular function and/or impending cardiac failure. 5. Decreases oxygen consumption and risk for decompensation. 6. To note response to activities or interventions. 7. To note effectiveness of medications. 8. To minimize or correct causative factors, maximize EVALUATION Short term objective: After 8 hours of rendering nursing care, outcome met. The patient was able to verbalize knowledge of the disease process, individual risk factors and treatment plan.

Objective cues: Distended Jugular vein noted Edema on lower extremities Restlessness noted

Long term objective: Within 3 days of rendering nursing care, the patient will be able to participate in activities that reduce the workload of the heart, such as stress management, therapeutic medication regimen program, balance activity or rest plan.

Long term objective: After 3 days of rendering nursing care outcome partially met. The patient was able to participate in some activities that reduce the workload of the heart, such as stress management, therapeutic medication regimen program, balance activity or rest plan.

T- 37.4 C P- 81 bpm R- 29 cpm BP-100/70 mmHg

as indicated. 9. Schedule activities and assessment. 10. Monitor rate of IV drugs closely

cardiac output. 9. To maximize sleep period. 10. To prevent overdose.