ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Data: Activity Long term goal: Independent: Long term goal:
Patient is a 60- Intolerance After 4hrs of 1. Check vital signs before 1. Orthostatic hypotension can After 4hrs of nursing
year-old female related to nursing and immediately after occur with activity because of interventions, the
presenting to imbalance interventions, activity during acute episode medication effect (vasodilation), patient was able to
the emergency between the patient will or exacerbation of HF, fluid shifts (diuresis), or achieve measurable
department oxygen be able to especially if client is compromised cardiac pumping increase in activity
with acute supply and achieve receiving vasodilators function. tolerance, evidenced
onset shortness demand as measurable (Hydralazine by reduced fatigue
of breath. evidenced by increase in ), diuretics and weakness and by
immobility, activity (hydrochlorothiazide), or vital signs within
Objective Data: weakness, tolerance, beta blockers (nebivolol). acceptable limits
- Swelling in her and dyspnea evidenced by 2. Document 2. Compromised myocardium during activity.
bilateral lower reduced cardiopulmonary response and inability to increase stroke
extremities fatigue and to activity. Note tachycardia, volume during activity may cause Short term goal:
- Immobility weakness and dysrhythmias, dyspnea, an immediate increase in heart After 30mins of
- Weakness by vital signs diaphoresis, and pallor. rate and oxygen demands, nursing interventions
- Fatigue within thereby aggravating weakness the patient was able
- Shortness of acceptable and fatigue. to participate in
breath/dyspnea limits during 3. Assess level of fatigue, 3. Fatigue because of advanced desired activities and
- V/S taken as activity. and evaluate for other HF can be profound and is meet own self-care
follows: precipitators and causes of related to hemodynamic, needs.
T: 97.3 F Short term fatigue. respiratory, and peripheral
PR: 74bpm goal: muscle abnormalities. Fatigue is
RR: 24cpm After 30mins of also a side effect of some
B/P: 104/54 nursing medications (e.g., beta blockers).
interventions Other key causes of fatigue
the patient will should be evaluated and treated
be able to as appropriate and desired.
participate in 4. Evaluate accelerating 4. May denote increasing cardiac
desired activity intolerance. decompensation rather than
activities and overactivity.
meet own self- 5. Provide assistance with 5. Meets client’s personal care
care needs. self-care activities, as needs without undue myocardial
indicated. Intersperse stress or excessive oxygen
activity with rest periods. demand.
6. A total of 30 minutes of 6. Because some patients may
physical activity three to five be severely debilitated, they may
times each week should be need to perform physical
encouraged. Before activities only 3 to 5 minutes at a
undertaking physical activity time, one to four times per day.
the patient should be given The patient then should be
the following safety advised to increase the duration
guidelines: of the activity, then the
• Begin with a few minutes frequency, before increasing the
of warm-up activities. intensity of the activity.
• Avoid performing physical
activities outside in extreme
hot, cold, or humid weather.
• Ensure that you are able
to talk during the physical
activity; if you are unable to
do so, decrease the intensity
of activity.
• Wait 2 hours after eating a
meal before performing the
physical activity.
• Stop the activity if severe
shortness of breath, pain, or
dizziness develops.
• End with cool-down
activities and a cool-down
period.
7. Barriers to performing an 7. To ensure pacing. Pacing and
activity are identified and prioritizing activities help
methods of adjusting an maintain the patient’s energy to
activity. The nurse helps the allow participation in regular
patient to identify peak and physical activity
 low periods of energy and
plan energy-consuming
activities for peak periods.
Collaborative:
8. Implement graded cardiac
rehabilitation and develop a
schedule that promotes
pacing and prioritization of
activities.
9. Referral to a cardiac
rehabilitation program may
be needed,
ROMERO, DYNA GISELLE Z. BSN 3Y1-2S
8. Strengthens and improves
cardiac function under stress if
cardiac dysfunction is not
irreversible. Gradual increase in
activity avoids excessive
myocardial workload and oxygen
consumption.
9. For HF patients with recent
myocardial infarction, recent
open-heart surgery, or increased
anxiety.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Objective Data: Excess fluid Long term goal: Independent: Long term goal:
- Shortness of volume After 8hrs of 1. Monitor urine output, 1. Urine output may be scanty After 8hrs of nursing
breath related to nursing noting amount and color, as and concentrated (especially interventions, the
- Tachypnea fluid interventions, well as time of day when during the day) because of patient was able to
- (+) wheezing retention the patient will diuresis occurs. reduced renal perfusion. demonstrate
noted, bilateral secondary to be able to Recumbency favors diuresis; stabilized fluid
rhonchi heart failure demonstrate therefore, urine output may be volume with
- Immobility as stabilized fluid increased at night or during balanced intake and
- Dry Skin manifested volume with bedrest output, breath
- Urinary by 2+ pitting balanced 2. Monitor 24-hour intake 2. Diuretic therapy may result in sounds clear or
frequency and edema intake and and output (I&O) balance. sudden or excessive fluid loss, clearing, vital signs
incontinence bilateral output, breath creating a circulating within acceptable
- BMI 40.2 lower sounds clear or hypovolemia, even though range, stable weight,
(Obese) extremities clearing, vital edema and ascites remains in the and absence of
- HEENT: signs within client with advanced HF or CHF. edema.
Bilateral acceptable 3. Maintain chair rest or 3. Recumbency increases
periorbital range, stable bedrest in semi-Fowler’s glomerular filtration and Short term goal:
edema present weight, and position during acute phase. decreases production of ADH, After 30mins of
- Cardio: 2+ absence of thereby enhancing diuresis. nursing
pitting edema edema. 4. Establish fluid intake 4. Involving client in therapy interventions, the
bilateral lower schedule if fluids are regimen may enhance sense of patient was able to
extremities Short term medically restricted, control and cooperation with verbalize
- V/S taken as goal: incorporating beverage restrictions. understanding of
follows: After 30mins of preferences when possible. individual dietary and
T: 97.3 F nursing Give frequent mouth care fluid restrictions.
PR: 74bpm interventions, and ice chips as part of fluid
RR: 24cpm the patient will allotment.
B/P: 104/54 be able to 5. Weigh daily. 5. Documents changes in or
verbalize resolution of edema in response
understanding to therapy. A gain of 5 lb
of individual represents approximately 2 L of
dietary and fluid. Conversely, diuretics can
fluid
restrictions.
6. Change position
frequently. Elevate feet
when sitting. Inspect skin
surface, keep dry, and
provide padding, as
indicated.
7. Position the patient or
teach the patient how to
assume a position that shifts
fluid away from the heart.
The number of pillows may
be increased, the head of
the bed may be elevated
(20- to 30-cm [8- to 10-inch]
blocks may be used), or the
patient may sit in a
comfortable armchair.
8. Investigate reports of
sudden extreme dyspnea
and air hunger, need to sit
straight up, sensation of
suffocation, feelings of panic
or impending doom.
result in rapid and excessive fluid
shifts and weight loss.
6. Edema formation, slowed
circulation, altered nutritional
intake, and prolonged immobility
or bedrest are cumulative
stressors that affect skin integrity
and require close supervision and
preventive interventions
7. In this position, the venous
return to the heart (preload) is
reduced, pulmonary congestion
is alleviated, and impingement of
the liver on the diaphragm is
minimized. The lower arms are
supported with pillows to
eliminate the fatigue caused by
the constant pull of their weight
on the shoulder muscles. Since
the patient has difficulty of
breathing at rest, she can sit
upright position on the side of
the bed with the feet supported
on a chair, the head and arms
resting on an overbed table, and
the lumbosacral spine supported
by a pillow.
8. May indicate development of
complications, such as
pulmonary edema or embolus,
which differs from orthopnea or
paroxysmal nocturnal dyspnea in
that it develops much more
rapidly and requires immediate

9. Note increased lethargy,
hypotension, and muscle
cramping.
10. Auscultate breath
sounds, noting decreased
and adventitious sounds, for
example, crackles and
wheezes. Note presence of
increased dyspnea,
tachypnea, orthopnea,
paroxysmal nocturnal
dyspnea, and persistent
cough.
11. Maintain fluid and
sodium restrictions, as
indicated. Assist the patient
to plan the fluid intake
throughout the day while
respecting the patient’s
dietary preferences.
Dependent:
12. Administer medications,
as indicated, such as
diuretics. Discussing the
timing of medication
administration is especially
important for elderly
patients, who may have
urinary urgency or
incontinence.
intervention.
9. These are signs of potassium
and sodium deficits that may
occur because of fluid shifts and
diuretic therapy.
10. Excess fluid volume often
leads to pulmonary congestion.
Symptoms of pulmonary edema
may reflect acute leftsided HF.
With right-sided HF, respiratory
symptoms of dyspnea, cough,
and orthopnea may have slower
onset, but are more difficult to
reverse.
11. Reduces total body water and
prevents fluid reaccumulation.
12. Increases rate of urine flow
and may inhibit reabsorption of
sodium and chloride in the renal
tubules. A single dose of a
diuretic may cause the patient to
excrete a large volume of fluid
shortly after administration
Collaborative: 13. May be necessary to provide
13. Consult with dietitian. diet acceptable to client that
meets caloric needs within
sodium restriction.