Problem: Pallor associated with bodyweakness

Pathophysiology: Failure of the left and/or right chambers of the heart results in
insufficient output to meet tissue needs and causes pulmonary and systemic
vascular congestion

Cues Nursing Objectives Intervention Rationale

Diagnosis s

Subjective: Decreased After 4 hours 1.Auscultate 1.Tachycardia is

SO of patient cardiac output in effective apical pulse; usually present,
verbalized related to nursing asses heart even at rest, to
luspad siya ug altered interventions, rate, rhythm compensate for
decreased
dali ra siya myocardial patient will
ventricular
kapuyon . di siya contractility report contractility.
ganahan nga decreased PACs, PAT, MAT
maglihok kay episodes of and atrial
maghangos daw weakness, fibrillation are
siya dyspnea, and common
participate in dysrhythmias
Objective: activities that associated with
Received reduce cardiac heart failure
patient workload
2.Note heart 2.S1 and S2
lying on sounds may be weak
bed with because of
ongoing diminished
IVF #2 pumping action.
D5W Gallop rhythm
regulated are common,
at KVO produces as
hooked at blood flows into
left arm non-compliant
3.Palpate chambers
infusing
peripheral
well with pulses 3. Decreased
O2 cardiac output
attached may be
via nasal reflected in
cannula diminished
@2L/ min radial, popliteal,
dorsalis pedis.
Body Pulses may be
fleeting or
malaise
irregular to
noted palpation, and
Pallor 4.Monitor BP pulsus alternas
noted may be present
Dyspneic
upon 4.In earthy,
major moderate or
chronic HF, BP
activities
5.Inspect skin may be
 V/S taken for pallor , elevated
as cyanosis because or
follows increased SVR.
T: 36.2 C
5.Pallor is
P: 110
indicative of
R: 35 diminished
BP:80/60 peripheral
perfusion
secondary to
inadequate
cardiac output,
6.Monitor urine vasoconstriction
output, noting , and anemia.
decreasing Cyanosis may
output and develop in
dark, refractory HF
concentrated
urine 6.Kidneys
respond to
7.Note changes reduced cardiac
in sensorium, output by
e.g. lethargy, retaining water
confusion and sodium
disorientation,
anxiety 7.May indicate
inadequate
8. Encourage cerebral
rest, semi perfusion
recumbent bed secondary to
or chair. decreased
cardiac output
Assist as
indicated 8.Physical rest
9.Provide should be be
bedside maintained
commode during acute or
refractory HF to
10.Elevate legs, improve
avoiding efficiency of
pressure under cardiac
knee. contraction
Encourage
active / passive 9.Commode use
exercises decreases work
of getting to
bathroom or
struggling to
use bedpan.

10.Decreases
venous stasis,
11.Check for and may reduce
calf tenderness; incidence of
diminished thrombus or
 pedal sounds; embolus
local redness, formation.
or pallor of
extremity 11.Reduced
cardiac output,
venous pooling /
stasis and
enforced
bedrest
increased risk of
thrombopheebiti
s

CUES NURSING PLAN INTERVENTIO RATIONALE

DIAGNOSIS NS

P- difficulty of Impaired After 8 hrs of 1. note respi. 1. tachypnea

breathing gas holistic Rate and depth, and dyspnea
work of accompany by
exchange r/t nursing care breathing ( use pulmonary
altered the pt. will of accessory obstruction,
S- maglisod ko og
oxygen be able to muscles/ nasal dyspnea and
ginhawa as
supply as demonstrate flaring, pursed- increased work of
verbalized by the lip breathing) breathing maybe
pt. evidence by improve first or only sing
O- dyspnea ventilation of sub-acute
Received secondary and pulmonary
patient lying to CHF adequate 2. auscultate embolus
on bed with lungs for area
oxygenation of dec./absent 2. non ventilated
ongoing IVF
#2 D5W of tissues by breath sounds may be identified
ABGs and the by absence of
regulated at
presence of breath sounds;
KVO hooked oximetry
adventitious crackles occur in
at left arm and to be sounds (eg. fluid filled tissues/
infusing well free from Crackles) airways or may
with o2 symptoms of reflect cardiac
attached via decompensation
respi.
nasal 3. monitor v/s.
cannula distress note change in 3. Tachycardia,
@3L/min cardiac rhythm. tachypnea. And
changes in BP.
Are associated
dyspneic
with advancing
with RR of hypovolemia and
35 cpm acidosis. Rhythm
alterations and
extra heart
restlessness sounds may
 noted reflect increased
cardiac workload
r/t
labored 4. assess worseningventilat
LOC/mental ion imbalance.
breathing,
changes
uses 4. systemic
accessory hypoxemia may
muscle in be demonstrated
breathing initially by
restlessness and
difficulty in 5. assess irritability, then
vocalizing activity by progressively
tolerance; decreased
encourage rest mentation
V/S taken as
periods, and
follows limit activities 5. these
T: 36.2 C to client patameters assist
P: 110 tolerance in determining
R: 35 client response to
BP:80/60 6. elevate the resumed
head of the bed activities and
as client ability to
requires/tolerat participate in self
es. care

6. promote
maximal chest
expansion,
7. assist with making it easier
frequency to breath and
changes of enhancing
position and get physiologic/
client out of psychologic
bed/ ambulated comfort.
as tolerated
7. turning and
8. assist client ambulation
to deal with fear enhance
anxiety that aerations of
may be present. different lung
segments,
thereby
improving oxygen
diffusion
9. provide
supplemental 8. feelings of fear
humidification; and severe
anxiety are
associated with
inability to
10. administer breathe and may
supplemental actually increase
oxygen
oxygen by
consumption/dem
 appropriate and
method
9. delivers
moisture to
mucous
membrane and
helps liquefy
secretions to
facilitate airway
clearance.

10.maximizes
available oxygen
for gas exchange,
reducing work of
breathing

CUES NURSING PLAN INTERVENTI RATIONALE

Diagnosis ON
P: decrease Decreased After 8 hours 1. Auscultate 1. Tachycardia is
cardiac output of nursing apical pulse; usually present
cardiac intervention assess heart even at rest to
SUBJECTIVE output the patient rate, and compensate for
rhythm. decreased
CUES: related to will
ventricular
no subjective altered display vital contractility
cues signs within
myocardial acceptable 2. Inspect skin 2. Pallor is an
OBJECTIVE: contractilit limits, for pallor, indicative of
Received y dysrhythmias cyanosis. diminished
patient controlled and peripheral
lying on no symptoms perfusion
bed with secondary to
of failure.
ongoing inadequate
IVF #2 cardiac output,
 D5W vasoconstriction
regulated ,and anemia.
at KVO Cyanosis may
hooked at 3. Monitor urine develop in
left arm output, refractory heart
infusing noting failure.
well with decreasing Dependent
o2 output and dark areas are often
attached or concentrated blue
via nasal urine or mottled as
cannula venous
@3L/min congestion
increases
Cold
clammy 3. Urine output
4. Note changes is usually
skin
in sensorium. decreased
noted during the day
dyspnea because of fluid
noted shifts into
Crackles tissues but may
noted be increased at
upon 5. Provide quiet night because
auscultati environment fluid returns to
on circulation when
patient is
V/S taken
recumbent.
as
follows 4. May indicate
T: 36.2 C inadequate
P: 110 cerebral
R: 35 6. Administer perfusion
BP:80/60 supplemental secondary to
oxygen as decreased
indicated cardiac
output.

7. Administer 5. Psychological
diuretics as rest help reduce
prescribed. emotional
stress,
which can
produce
vasoconstriction
, elevating BP
andincreasing
heart rate or
work.

6. Increases
available
oxygen for
myocardial
uptake to
 combat effects
of hypoxia or
ischemia.

7. Diuretics, in
conjunction with
restriction of
dietary sodium
and fluids, often
lead to clinical
improvement in
patients with
heart failure

CUES NURSINGDIAG PLAN INTERVENTI RATIONALE

NOSIS ON

P- body malaise Activity After 8 hrs. 1. check v/s 1. orthostatic

intolerance r/t of holistic before and hypotension
immediately can occur with
imbalanced bet. nursing care after activity, activity
S Luya kaau
Oxygen supply the pt. will esp. if pt. is because of
akong lawas as receiving med. Effect.
and demand as be able to
verbalized by
the patient evidenced by reduce vasodilators. Fluid shift or
weakness and weakness Diuretics or B- compromised
O blockers cardiac
dysnea. and pumping fxn.
Received maintain
mobility @ 2. document 2. compromised
patient
the highest cardiopulmonar myocardium/in
lying on y response to ability to inc.
bed with possible activity. Note stroke vol.
ongoing level. tachycardia, during activity
IVF #2 dysrythmias. may cause an
D5W Dysonea. immecliate inc.
regulated Diaphoresis in HR and
at KVO pallor. oxygen
hooked at demands.
left arm Thereby
infusing aggravating
weakness
well with 3. encourage fatigue
o2 rest initially.
attached Thereafter, limit 3. reduces
via nasal activity on basis myocardial
cannula of pain/ adverse workload/oxyge
@3L/min cardiac n consumption
response. reducing risk of
Body Provide complications
nonstress
malaise
divertional
noted activities.
Cold
clammy 4. instruct 4. Activities
skin noted client to avoid that req.
dyspnea increasing holding the
noted abdominal breath and
V/S taken pressure bearing down
as (valsavas
maneuver) can
follows
result in
T: 36.2 C bradycardia
P: 110 (temporarily
R: 35 reduced cardiac
BP:80/60 output) and
rebound
tachycardia
with elevated
BP.
5. provide
assistance with 5. meets clients
self care personal care
activities as needs without
indicated. myocardial
Interperse with stress/
rest periods excessive
oxygen
6. assess for demand.
other
precipitators / 6. fatigue is a
causes of side effect of
fatigue(treatme some meds.
nt, pain, meds ( beta-blockers,
tranquilizers
and sedatives.
7. evaluate
accelerating 7. may denote
activity increasing
intolerance cardiac
decompensatio
n rather than
over activity
8. explain
pattern of 8. progressive
graded inc.of activity
activity level, provides
(eg. Getting up controlled
to commode or demand on the
sitting in chair, heart,
progressive increasing
ambulation and strength and
resting after preventing over
meals. exertion

9. review s/sx
reflecting 9. Palpitations,
intolerance of pulse
present activity irregularities
level or req. develop of
notification of chest pain or
nurse/physician dyspnea may
indicate need
for changes in
10. implement exercise
graded cardiac regimen or
rehabilitation/ medication.
activity
10. Strengthen
program and improves
cardiac fxn
under stress if
cardiac dysfxn
is not
irreversible.
Gradual
increase in
activity avoids
excessive
myocardial
workload and
oxygen
consumption