PATIENT NAME: BON, CESAR JR

AGE/SEX: 48/M

NURSING STUDENT: REY T. LADERA ( NR-42)

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATION

N
 SUBJECTIVE  Ineffective  Cardiomyopat SHORT TERM:  Monitor  To have  The patient
Nahihirapan tissue After 3 hrs of CV base line shall have
hy is an
ako minsan perfussion nursing status & data demonstrate
abnormality of VS
huminga at related to the cardiac interventions the d behaviors
minsan po decreased
muscle that
patient will be  To have on how to
sumasakit cardiac able to  Assess base line effective
leads to demonstrate
dibdib ko. " as output Oxygen data and airways
verbalized the functional behaviors on how ation, this are
patient " changes or to effective Apply usually
impairment. airways. O2 as altered in
needed
 OBJECTIVE There are the
three types: LONG TERM: condition.
Vital sign Dilated, After 2 days of
Hypertrophic, nursing
 Encoura  A warm
BP: 130/80 and interventions the ge rest environm
Temp:36.9 Restrictive. patient will free and ent
RR:67 from shortness of minimiz promotes
PR:16 breathing e stress vasodilati
on which
decreased
preload
 Monitor
and
for s/s
heart promotes
failure tissue
perfussion
.
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTIO RATIONALE EVALUATION
N
 SUBJECTIVE  decreased  Cardiomyopat LONG TERM:  Assess  To have  The patient
nahihirapan po cardiac Nursing Oxygen base line shall have
hy is an
ako huminga. output interventions the ation, data participate in
abnormality of Apply
"as verbalized related to the cardiac patient will O2 as activities to
the patient " increased
muscle that
participate needed  To have decrease in
vascular activities to base line the heart
leads to
 OBJECTIVE resistance. decrease in the data and workload.
functional heart workload. this are
Vital sign changes or  Encoura usually
impairment. ge rest altered in
BP: 120/80 There are and the
three types: minimiz
Temp:36.8 condition.
e stress
RR:69 Dilated,
PR:15 Hypertrophic,  A warm
and environm
Restrictive.  Monitor ent
for s/s promotes
heart vasodilati
failure on which
decreased
preload
and
 reinforce promotes
d low
salt and tissue
low fat perfussion
diet .
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

OBJECTIVE  acute pain  Cardiomyopat The patient will  Assess  To have  The
related to expression Oxygenation base line patient
hy is an
Difficulty of imbalance of decreased and will , Apply O2 data shall have
abnormality as needed
breathing oxygen supply of the cardiac be free from the participate
to myocardial
muscle that
complications of  To have in
Vital sign demands the condition. . base line activities
leads to
 assess data and to
BP: 120/80 functional this are decrease
patient
Temp:36.8 changes or condition usually in the
RR:69 impairment. altered in heart
PR:15 There are the workload.
three types: condition.
Dilated, 
administere  A warm
Hypertrophic, d prescribed
and medication.
environme
Restrictive. nt
 Monitor for promotes
s/s heart vasodilatio
failure n which
decreased
preload
and
 reinforced promotes
low salt and tissue
low fat diet
perfussion.
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE  Activity  Cardiomyopat SHORT TERM:  Assess  To have  After

intolerance Oxygenation base line series of
hy is an
“mabilis ako related to Improvement in , Apply O2 data nursing
abnormality as needed
mapagod compromised of the cardiac the blood flow to interventi
kapag oxygen
muscle that
extremities.  To have ons goals
naglalakad transport base line partially
po ako “ as
leads to LONG TERM:
secondary to  assess data and met as
verbalized CHF functional this are evident at
patient
the patient “ changes or full improvement condition usually the client
impairment. in the oxygen altered in partial
OBJECTIVE There are transport including the improvem
three types: its perfusion condition. ent in skin
Body Dilated, function  condition
weakness administere  A warm from cold
Hypertrophic, d prescribed
and environme and
medication.
fatigue Restrictive. nt clammy to
Vital sign promotes normal
 Monitor for
s/s heart vasodilatio skin..
BP: 120/80 failure n which
Temp:37.1 decreased
RR:71 preload
PR:17 and
 reinforced promotes
low salt and tissue
low fat diet
perfussion.
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

 Decreased  Cardiomyopat after 8 hours of  Auscultate  To have  after 8

OBJECTIVE cardiac output nursing apical pulse base line hours of
hy is an
related to intervention the assess heart data nursing
abnormality rate and
altered of the cardiac patient will display rhythm. interventi
Vital sign myocardial
muscle that
vital signs within  To have on the
contractility acceptable limits. base line patient
BP: 120/80
leads to Dysrhythmias
changes data and will
Temp:37.1 functional controlled and no this are display
 Inspect skin
RR:71 changes or symptoms of for pallor usually vital signs
PR:17 impairment. failure cyanosis. altered in within
There are the acceptable
three types: condition. limits.
Dilated, Dysrhyth
 administere  A warm mias
Hypertrophic, d prescribed
and environme controlled
medication.
Restrictive. nt and no
promotes symptoms
 Monitor for
s/s heart vasodilatio of failure
failure n which
decreased
preload
and
 reinforced promotes
low salt and tissue
low fat diet
perfussion.
 DRUG STUDY

INDICATION/ MECHANISM OF SIDE EFFECTS/ NURSING CONSIDERATIONS

CONTRAINDICATION ACTION ADVERSE
EFFECTS

INDICATIONS: Inhibit reabsorption of low blood Assess patient’s nderlying condition

sodium and water in pressure, before starting theraphy.
Generic Name: Edema due to cardiac, the ascending limb of dehydration and Monitor for renal cardiac,neurologic, GI
furosemide hepatic & renal the loop of Henle by electrolyte manifestations of hypokalemia.
disease, burns; mild to interfering with the depletion (for Monitor for CNS, GI, cardiovascular,
Brand Name: moderate HTN, chloride binding site of example, sodium, integumentarym neurologic
Lasix hypertensive crisis, the 1Na+, 1K+, 2Cl- potassium). manifestations of jypocalcemia,
acute heart failure, cotransport system. jaundice, Monitor for CNS, hyperactive reflexes,
Classification: reduced urinary output Loop diuretics ringing in the ears depressed cardiac output,nausea,
Diuretics due to gestoses, increase the rate of (tinnitus), vomiting, tachycardia
chronic renal failure, delivery of tubular fluid sensitivity to light Assess fluid volume status(urine,color,
Dosage: nephrotic syndrome. and electrolytes to the (photophobia), quality and specific gravity)
5mg(0.5ml) distal sites of rash, Assess patient tinnitus, or pain
CONTRADICTIONS
: hydrogen and pancreatitis,
Frequency: potassium ion nausea,
Anuria; hepatic coma
Every 12 hours. Hold secretion, while diarrhea,
& precoma; severe
for BP less than 85 plasma volume abdominal pain,
hypokalemia &/or
systolic contraction increases and dizziness.
hyponatremia;
hypovolemia w/ or w/o aldosterone Increased blood
Route: production. The sugar and uric acid
hypotension.
IV Push increased delivery and levels
Hypersensitivity to
sulfonamides. high aldosterone
levels promote sodium
reabsorption at the
distal tubules, thus
increasing the loss of
potassium and
hydrogen ions.
 INDICATION/ MECHANISM OF SIDE EFFECTS/ NURSING CONSIDERATIONS
CONTRAINDICATION ACTION ADVERSE EFFECTS

INDICATIONS: Trimetazidine is a  Nausea and  Use cautiously in patients with

cellular acting anti- vomiting heart failure or hypertension
Generic Name: This drug is ischaemic it has 3 and in elderly patients
trimetazidine recommended in long main properties by  Fever
term treatment of which it acts as a
Brand Name: coronary insufficiency cytoprotective agent.  Rash
vastarel angina pictoris It inhibits the
anaerobic glycolysis  Respiratory
and fatty acid illness
metabolism
 Anemia
 INDICATION/ MECHANISM OF SIDE EFFECTS/ NURSING CONSIDERATIONS
CONTRAINDICATION ACTION ADVERSE EFFECTS

INDICATIONS: Trimetazidine is a  Nausea and  Use cautiously in patients with

cellular acting anti- vomiting heart failure or hypertension
Generic Name: This drug is ischaemic it has 3 and in elderly patients
trimetazidine recommended in long main properties by  Fever
term treatment of which it acts as a
Brand Name: coronary insufficiency cytoprotective agent.  Rash
vastarel angina pictoris It inhibits the
anaerobic glycolysis  Respiratory
and fatty acid illness
metabolism
 Anemia
 NURSING CARE
PLAN/DRUG
STUDY
REY T. LADERA
NR-42/ GROUP 5
C.I: Mrs. Ludivina Linezo