NURSING CARE PLAN

ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONAL EVALUATION

Objective data :
1..Decreased Cardiac To improve 1.. Assess heart rate 1. Most patients have Child demonstrates
 Hypertension ability to compensatory tachycardia and adequate cardiac
Output: Inadequate
and blood pressure.
 Bounding tolerate low blood pressure in response output as evidenced
pulse blood pumped by the activity to reduced cardiac output. by blood pressure,
 Tachycardia without pulse rate, rhythm
heart to meet dyspnea, 2. Cold, clammy and pale skin is within normal
2. Note skin colour, temperature
metabolic demands of chest pain. secondary to a compensatory parameters; strong
and moisture. increase in sympathetic nervous peripheral pulses and
the body related to system stimulation and low ability to tolerate
structural factors of cardiac output and oxygen activity without
desaturation. symptoms of
congenital heart defect
dyspnea, syncope
as evidenced by 3..Check for peripheral pulses,
3. Weak pulses are present in
or chest pain.
reduced stroke volume and
variations in including capillary refill. cardiac output. Capillary refill is
hemodynamic sometimes slow or absent.
readings, widened 4. Close monitoring serves as a
4. Assess for fatigue and reduced guide for optimal progression of
pulse pressure, ECG
activity tolerance. activity.
changes, arrhythmias,
murmur, fatigue, 5. Compromised regulatory
5. Inspect fluid balance and mechanisms may result in fluid
dyspnea, Cyanosis. weight gain. Weigh patient and sodium retention; weight is
regularly prior to breakfast. an indicator of fluid balance.

6. Cardiac dysrhythmias may

6. Monitor electrocardiogram occur from low perfusion,
(ECG) for rate, rhythm, and acidosis, or hypoxia.
ectopy. Tachycardia, bradycardia, and
ectopic beats can further
compromise cardiac output.
Older patients are especially
sensitive to the loss of atrial kick
in atrial fibrillation.

7. Rest decreases metabolic rate,

7. Provide adequate rest periods. decreasing myocardial and
oxygen demand.

8. The failing heart may not be

8. Administer oxygen therapy as able to respond to increased
prescribed. oxygen demands.

9. It
9. Administer medications as  increases contractility of
prescribed : the heart and force of
 Digoxin contraction.
 decreases edema
 Frusemide formation and diminish
afterload.
ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONAL EVALUATION

Objective data :
2. Activity intolerance To promote 1. Assess level of fatigue, 1. Provides information Child will tolerate
 Fatigue optimal
ability to perform ADL.
about energy reserves and increased activity as
 Dyspnea related to generalized physical response to activity. evidenced by normal
weakness, imbalance activity. fluctuation of vital
2. Indicated hypoxia and signs during physical
between oxygen increased oxygen need during activity.
2. Assess dyspnea on
supply and demand as exergy expenditure.
exertion, skin colour
evidenced by presence changes during rest and 3. Promotes rest and conserves
of respiratory when active. energy.
problem, fatigue,
3. Allow for rest periods 4. Provides baseline information
needs to rest after
between care to discontinue activity if patient
short period of play, has chest pain, dizziness.
abnormal heart rate or 4. Obtain vital signs
immediately after activity. 5. Conserves energy
blood pressure
response to activity,
6. Promotes growth, diversion,
exertional dyspnea. 5. Avoid allowing infant to cry physical and mental
for long period of time development.

6. Provide toys and games for

quiet play and diversion, allow 7. Avoids fatigue.
to limit own activities as much
as possible.

7. Explain to parents need to

conserve energy and encourage
 rest.

ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONAL EVALUATION

3. Compromised
Objective data : To help 1. Observe for erratic 1. Information affecting the Family will cope more
 Pain score family coping related family behaviors (anger, ability of the family to cope with effectively.
6/10 to situational and members tension, disorganization), infant/child’s cardiac condition.
 Guarding verbalize perception of crisis situation.
sign developmental crises feelings 2. Provides information about
 Limited of family and child as related to 2. Assess need for information need for intervention to relieve
movement emotional and support. anxiety and concern.
evidenced by state.
verbalization when 3. Identifies need to develop
3. Assess usual family coping new coping skills if existing
family expresses methods and effectiveness. methods are ineffective in
concern changing behaviors exhibited.
and fear about 4. Reduces anxiety and enhances
infant/child’s disease 4. Encourage expression of family’s understanding.
feelings and provide factual
and condition. information about their child. 5. Prevents unnecessary anxiety
resulting from inaccurate
5. Clarify any misinformation knowledge or beliefs.
and answer questions regarding
disease process. 6. Chronic anxiety, fatigue and
isolation will affect care
capabilities of family.
6. Encourage to maintain health
of family members and social
contacts.
ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONAL EVALUATION

Objective data : 4. Impaired gas To maintain 1. Assess respirations, note 1. Rapid and shallow breathing Patient maintains
 Dyspnea exchange related to optimal gas quality, rate, rhythm, depth, use pattern, hypoventilation affect optimal gas exchange as
 Spo2 :84 % exchange of accessory muscles. gas exchange. evidenced by absence of
mucus in airway
dyspnea and
 Reslessness secondary to restlessness.
mechanical ventilator 2. Perform endotracheal tube 2. To clear the airway from
support as evidenced and oral suctioning. secretions.
by presence of
abnormal breath 3. Assess lungs for areas of 3. Any irregularity of breath
sounds, oral decreased ventilation and sounds may disclose cause of
secretions, productive auscultate presence of impaired gas exchange.
cough, restlessness. adventitious breath sounds.

4.Assess patient’s hydration 4. Overhydration may impair gas

status. exchange in patients with heart
failure.

5. Provide nebulisation and chest 5. To mobilize secretions

physiotherapy as indicated.

6. Monitor patient’s behaviour 6. It is an early sign of impaired

for onset of restlessness, gas exchange.
agitation, confusion.

7.Monitor for alteration in Blood 7. Blood pressure, heart rate and

Pressure and heart rate. respiratory rate all increase with
hypoxia and hypercapnia.
 8. Note Arterial blood gas levels. 8. Increasing PaCo2 and
decreasing PaO2 are signs of
respiratory acidosis, hypoxemia.
ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONALE EVALUATION
Objective data : 5. Acute pain related To reduce 1. Assess for location, duration, 1. This is the first step in After series of nursing
 Restlessness to post surgical pain intensity and onset of pain. planning pain management. intervention pain
 Pain score procedure as reduced to some
5/10. evidenced by facial 2. Monitor vital signs and pain 2. For future comparison after extent as evidenced by
 Verbalization grimace, verbal report score. intervention. pain score 1/10.
of pain of pain, pain score
complain. 5/10 3. Administer analgesics as 3. To reduce pain
prescribed by physicians.

4. Provide calm and quite 4. To promote sleep

environment.

5. Provide comfortable position 5. Change in position may

to the client. reduce pain to some extent.

6. Provide rest periods to 6. Peaceful quiet environment

promote relief, sleep and facilitate rest and acts as
relaxation. diversional therapy.
ASSESSMENT DIAGNOSIS GOAL PLANNING RATIONALE EVALUATION
Objective data : 6. Altered body To promote 1. Assess vital signs of patient 1. To know the baseline data Patients body
 Temperature temperature below thermo- hourly. temperature reaches
– 95 F. normal range related regulation within normal limit as
 Cold skin to decreased 2. Assess environmental 2. It will help in maintaining evidenced by body
 Shivering metabolic rate, temperature and provide patient’s temperature. temperature of 97.4 F.
exposure to cold warming blankets, increase room
environment, extreme temperature.
evaporation heat loss
from skin, poor 3. Assess patient’s peripheral 3. Peripheral vascular
clothing as evidenced perfusion at frequent intervals. constriction minimize heat loss
by shivering, cold from extremities.
extremities, body
temperature 95 F. 4. Monitor fluid intake and urine 4. Decreased output indicated
output. dehydration or poor renal
perfusion.

Objective data : 7. Fear and anxiety in To reduce 1. Explain the family members 1. To reduce anxiety Patient’s fear and
 Temperature child and family fear and about the disease process, anxiety reduced to a
– 95 F. anxiety examinations and treatment. manageable level.
members related to
 Cold skin invasive procedure,
 Shivering hospitalization as 2. Convey an attitude of 2.Being supportive and
evidenced by empathy (silence, allowing approachable promotes
crying, speaking, listening). communication.

3. Encourage parents to 3. To diminish feelings of fear.

accompany children.

4. Encourage use of spiritual 4. Provides opportunity to

 resources. clarify reality of fear and reduce
anxiety to manageable level.

5. Encourage family members to 5. To decrease level of anxiety.

express feelings, perceptions of
fear.

6. Provide recreational and 6. To reduce fear in child.

diversional therapy to the child
according to his age group.

8. Potential for To reduce 1. .Assess temperature, IV site if 1. Provides information Patient remains free of
infection related to risk for present, increased WBC, indicating potential infection infection.
chronic illness infection increased pulse and respiration. .

2. Avoid allowing those with 2. Prevents transmission of

infections to have contact with infectious agent to children with
infant / child. compromised defense.

3. Provide adequate rest and 3. Protects against potential

nutritional needs for age. infection by increasing body
resistance and defences.

4. Wash hands before giving 4. Prevents transmission of

care. microorganisms to infant / child.

5. Prevents reduced defences or

5. Instruct parents and child in exposure to possible
personal hygiene and practices. contsminants

6. Infections are easily

6. Inform to avoid contact with transmitted to a debilitated child.
 those in family or friends that
have an infection

HEALTH EDUCATION :

Seek medical care immediately if –

 Child has fever
 Child has chills, cough, feels weak
 Swelling in ankles or feet
 Feeding problem, reduced appetite

Medication

 Give medications as directed by physicians like heart medicine, diuretics.

Diet
 Provide healthy foods including fruits, vegetables, low fat dairy products.

Physical activity and exercise

 Encourage light physical activity

 Keep the child from crying for too long for first 3 to 4 weeks.
 Donot pull or lift the child by arms or from their armpit
 Prevent child from doing any activity that involve pulling or pushing with arms.

Wound care

 Observe incision site for signs of redness, swelling, tenderness, warmth or drainage.
Lifestyle

 Donot smoke around the child.

 Keep child’s teeth clean and healthy as cavities increase risk for endocarditis.
 Encourage to maintain personal hygiene

Vaccination

 Vaccination can help protect child from infections such as influenza.

Follow up

 Encourage the patient to come for regular health check-up after the discharges

Conclusion

Congenital Heart defects are very common and detection of CHD is increasing. As medical care anf treatment have improved, babies and
children with congenital heart defects are living longer and healthier lives. On going, appropriate medical care can help children and adults with
a CHD live as healthy as possible.
REFERENCE
 Brunner & Suddharth’s, “Textbook of Medical Surgical Nursing”, (2010), twelfth edition, volume 1, publishers wolters kluwer (India)
pvt.Ltd, New Delhi, page no.684 to 721.

 Black Joyce M., Hawks Jane Hokanson,” Textbook of Medical Surgical Nursing”, (2008), 8th edition, volume 1, publishers Elsevier
Science Health Division.

 Dutta Parul, “Textbook of pediatric nursing”, 2nd edition 2009, Jaypee brothers medical publications Ltd, New Delhi.

 WWW.PUBMED.COM, Journal of American Cardiology

 www.nurseslabs.com