NOVILYN C.

PATARAY
BSN - II
ASSESSMENT DIAGNOSIS PATHOPHYSIOLOG PLANNING INTEREVENTION RATIONALE EVALUATION
Y
Subjective: Decreased Inadequate blood After 1 hour of  Assess  Early After 1 hour of
“maririgatan nga cardiac pumped by the heart nursing potential for detection of nursing intervention,
umangesetoy anak output to meet the metabolic interventions, the type of changes the patient was able
ko ken nadagsen ti related to demands of the body. patient will be able developing promotes to breathe within
barukong na” as altered to alleviate shock states timely normal range and
verbalized by the myocardial feelings of chest intervention decrease feeling of
mother. contractility pain and to limit chest pain.
evidenced by shortness of degree of
Objective: mitral breath. cardiac
 Restlessnes stenosis/ dysfunction
s accumulation  Monitor vital  To determine
 Dyspnea of fibrin on signs degree of
 Edema mitral valve frequently assistance
 Pallor needed by
 Clammy skin the patient
 Prolonged and note
capillary refill response to
 V/S taken as activities
follows:  Monitor intake  To decrease
T- 36 and output oxygen
PR-86 consumption
RR-12 and risk for
BP-90/60 decompensa
tion