Nursing Rationale Evaluation

Nursing intervention
:DX
DX(1):impaired gas Every 4 hours, and with papillary muscle .1 No shotness of breath , .1
exchanig related to chest discomfort or dysfunction can be .dyspnea on exertion
congestive heart symptoms , assess, valve regurgitation
. failure document , and report to and reduction stroke skin color and temperature .2
the physician abnormal . volume .normal
heart sounds (s3- crackles result it .2
s4)gallop or new murmur pulmonary congestion spo2,pao2 ,paco2.3
abnormal breath sounds from increased heart
(particularly crackles ), .pressures Within normal limit .
Goal: Absence of decreased oxygenation .
.respiratory distress . and activity intolerance 4. appears comfortable and

.rested

DX2: Decreased cardiac monitar cardiovascular.1 Effectiveness of .1 : Normal rangs of.1

output related to valve status serial reading cardiac output is Arterial pressure
.regurgitation .blood pressure determined by CVP
Auscultation of heart .2 continuous monitoring Pulmonary artery pressure
.sound and rhythm . Heart sound
abserve for .3 duskiness and .2 Cardiac output and cardiac
hypotention and rising cyanosis may indicate index
.CVP\ Tachycardia decreased cardiac Peripheral pulses
Goal:Restoration of .output Cardiac rate and rhythm
cardiac output normal cool moist skin .3 Cardiac biomarkers
.limit indication Urine output
vasovonstriction and Skin and mucosal color
decrease cardiac .Skin temperature
.output
DX(3):Chronic pain promote increased .1 Enhancement of .1 Uses measure to increase .1
related to impaired .circulation peripheral circulation arterial blood supply to
ability of peripheral increases the oxygen .extremities
vessels to supply tissues supplied to the muscle
.with oxygen and decreases the
Administer analgesic .2 accumulation of
agents as pre-scribed metabolites the cause
with appropriate nursing .muscle spasm Uses analgesic agent as .2
.Goal: Relief of pain . consideration .prescribed
Analgesic agent help.2
reduce pain and allow
the patient to
participate in activites
and exercises that
.promote circulation
DX(4): imbalance fluid monitor and record .1 fluid management .1 patient is adequately .1
volume related to hourly intake and output be altered . patient : hydrated , as evidenced by
congestive heart .urine output should be response to and for
failure. . at least 30ml\h fluid management urine output greater than*
Administer blood .2 . must be assessed 30ml\h
component therapy and pulmonary edema .2 vital sign stable ,heart *
Goal:Maintenance of parenteral fluids and \or due to transfusion or rate
adequate fluid volume diuretics as prescribed to fluid overload is an and central venous
restore and maintaion ever –present threat pressure
.fluid volume becease .approaching normal
Because of congestive No excessive peripheral *
.heart failure edema

Dx(5):anxiety related to Assess ,document , .1 provide information .1 .Report less anxiety.1

. cardiac event and report to the about psychology well
physician and family s being causes of patient and family discuss .2
level of anxiety and .anxiety are variable their anxieties and fear about
.coping mechanisms if a patient finds .2 . illness and death
Assess the need for .2 support in a religion
Goal: reduction of spiritual counseling refer spiritual counseling patient and family appear less.3
.anxiety .as appropriate may assist in reducing . anxious
.anxiety and fear participates actively in a .4
Assess the need for .3 social services can .3 progressive rehabilitation
.social service referral assist with post . programe
hospital care and practices stress reduction .5
.financial concerns .techniques
 Bethlehem University
Faculty of nursing and health Science
MEDICAL SURGICAL 334\335
Care plan

subject:care plan of ( CHF ).

.Prepared by:saja fareed ayyash

.Presented to:Hala Kasbari

Refarence:saintJosephhospital(medical)
.Student No:1202190

.Semester:Spring 2014