NURSING CARE PLAN

ASSESSMENT NURSING RATIONALE PLANNING NURSING ACTION RATIONALE EVALUATION

DIAGNOSIS
Subjective Cues: Decreased Cardiac STG:  Assessed for and document the ff: At the end of 8-hour
N/A Output related to Occlusion in the At the end of 30- o Mental Status  Cerebral perfusion is Nursing Interventions, the
altered heart rate artery min Nursing directly r/t cardiac output goal was partially met as
Objective Cues: and rhythm 2o MI Interventions, the and aortic perfusion evidenced by:
 Generalized Decreased blood client will be able pressure and is influenced
paleness supply to: by hypoxia and electrolyte  PR =
noted  Demonstrate and acid-base variation  Cardiac monitoring
 Irregular Decreased hemodynamic o Lung sounds  Crackles may develop r/t revealed slight
rhythm of venous return stability (blood alterations in MI disturbance
pulse noted pressure and o Blood Pressure  Hypotension r/t
 Decreased cardiac output) hypoperfusion, vagal
amount of blood by 20% – 30% as stimulation, dysrhythmias, Endorsed to the next shift
expelled by revealed in the or ventricular dysfunction NOD for further
ventricles cardiac monitor may occur interventions and revisions
 PR = o Heart Sounds  Bradycardia may be present of NCP for continuity of
Decreased LTG: because of vagal care
cardiac output At the end of 8-hour stimulation or conduction
Nursing disturbances r/t area of MI
Interventions, the o Urine Output  Urine output
client will be able <0.5mL/kg/hrmay reflect
to: reduced renal perfusion and
 Demonstrate glomerular filtration as a
hemodynamic result of reduced cardiac
stability (Blood output
pressure and o Peripheral Perfusion  Decreased may indicate a
cardiac output) decreased cardiac output
by 31%-80% as -MSN, Black and Hawks,
revealed in the Vol. 2, 7th edition
cardiac monitor  Kept client on bed in Semi-fowler’s  Facilitate oxygenation
 Manifest and administered high flow O2 via -NANDA, Doenges,
absence of nasal cannula Moorhouse, Murr, 11th
angina edition
 Monitored and assessed angina for  Angina indicates
type, severity and duration myocardial ischemia, which
may decrease cardiac
ouput
-MSN, Black and Hawks,
Vol. 2, 7th edition
 Administered beta-blockers and  To determine effects of
inotropin agents and monitored therapy
their effects