COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF NURSING
HOLY NAME UNIVERSITY
CITY OF TAGBILARAN

NURSING CARE PLAN

Name of Patient: ________________V. G__________________ Age: ___76__ Status:____________Married____________

Address: _______Sitio Libjo, Barangay Ulbujan, Calape Bohol_______ Date: ____N/A____ Ward: ______N/A________ Bed No: __N/A__
Impression:______Exertional Dyspnea, Fatigue, Activity Intolerance______________________________________________________________________

ASSESSMENT/ DIAGNOSIS PLANNING INTERVENTION EVALUATION

PROBLEM RATIONALE OF THE DESIRED BEHAVIORAL NURSING RATIONALE
CUES/NRSG. DX PROBLEM OUTCOME(S) OUTCOME(S) INTERVENTIONS
Nsg Dx: Decreased When there is an -After 3 days of -After 8hrs of Independent GOAL
Cardiac Output related underlying disease, nursing nursing ● Monitor Blood ● In order to assess PARTIALLY
to altered heart illness, and/or injury that intervention, the intervention, the pressure, Pulse, and how well the MET:
contractility as affects the heart, the patient will patient will be able condition before patient is tolerating
manifested by poor volume of blood being demonstrate to demonstrate giving/administering the current Patient was able
activity tolerance pumped throughout the excellent cardiac improving cardiac medications. medication before to demonstrate
rest of the body is output as evidence administering any improved cardiac
output as evidence
Subjective: usually affected. In the by: cardiac medication. output as
by:
● “Maka bati ko aksyon case of Coronary Artery ● improved blood ● Assist the patient in ● Since the patient is evidenced by a
ug ka luya kong Disease (CAD), the pressure within ● stabilized pulse self-care activities easily fatigued and stable baseline
magpalabi ko ug lihok narrowing and blockage the desired range within normal and during prone to dyspnea, blood pressure of
sa mga buhaton diri sa of the arteries influences of 100-120/80-90 range ambulation as assisting them 130/85, and
balay” as verbalized the amount of blood mmHg needed avoids injuries and decreased
by the patient. flow to the heart, ● normal baseline ● decreased accidents. episodes of
causing the heart to V/S episodes of ● Encourage deep ● Various breathing dyspnea.
Objective: work harder to ● improved fatigue breathing exercises techniques
● Baseline V/S compensate. As a result activity and breathing supplement oxygen
of these various factors, tolerance. ● decreased techniques. to the lungs during
○ T- 36.5°C
 ○ BP- 135/90 the heart cannot work episodes of inspiration and
mmHG properly and the ability exertional prevent difficulty
○ P- 65bpm (weak to pump blood dyspnea in breathing.
pulse) throughout the rest of Dependent
○ RR- 22bpm the body is adversely ● Administer ● Supplemental
● cold, clammy skin affected resulting in supplemental oxygen oxygen meets the
decreased tissue as prescribed by the body’s demand for
● fatigue and dyspnea perfusion. Impaired oxygen and avoids
physician
upon exertion tissue perfusion affects hypoxia and
■ the cells and tissue’s ischemia.
ability to stay ● Diuretics is usually
oxygenated and thus prescribed to
manifesting in various ● Administer diuretics patients with
symptoms such as as prescribed by the hypertension and
impaired activity physician improves the
tolerance, fatigue, body’s discharge
dyspnea, etc. of unnecessary
fluid build up.

Source:
https://www.medicalnew
stoday.com/articles/1501
09#:~:text=Hypertension
%20is%20another
%20name%20for,walls
%20of%20their
%20blood%20vessels.