TABIJE, ARVIE JAYSELLE P.

1. Josef came in with chief complains of hypertension, swelling of legs and feet and stated that as if his belt is too tight. BP is 150/100 mmHg, narrow pulse pressure, and
with PR of 90 bpm. ECG was done revealing atrial fibrillation, persistent ST segment abnormalities, and decreased QRS amplitude. Upon auscultation, an S3 sound was
hear and the S1 and S2 sounds were softened. Peripheral pulses are diminished evidenced by distended jugular veins. He is pale and with slow capillary refill. His
respiratory rate is 30bpm and with use of accessory muscles accompanied by nasal flaring. He also reports having dyspnea on exertion and having dry, hacking, non-
productive cough. Urine output is 15 mL/hour.

1. Identify the S and O

2. Group them according to your medical-surgical assessment tool
3. Construct your nursing diagnoses (done- see last part)
4. Make your nursing care plans (minimum of 2 actual problems)

1.
S: complains of hypertension, stated that he is pale and with slow capillary refill. He also reports having dyspnea on exertion and having dry, hacking, non-
productive cough.
O: swelling of legs and feet, BP is 150/100mmHg, narrow pulse pressure, PR of 90 bpm, ECG has atrial fibrillation, persistent ST segment abnormalities,
decreased QRS, amplitude, s3 sound was heard, s1 and s2 sounds were softened, peripheral pulses are diminished, RR of 30bpm,

ASSESSMENT EXPLANATION OF OBJECTIVES NURSING RATIONALE EVALUATION

THE PROBLEM INTERVENTIONS
S: complains of In my nursing STO: Dx: STO:
hypertension, stated that diagnosis, the activity After 3-8 hours of -Monitor vital signs -To help determine patient’s Goal partially met because
he is pale and with slow
capillary refill. He also
reports having dyspnea
on exertion and having
dry, hacking, non-
productive cough.
O: swelling of legs and
feet, BP is
150/100mmHg, narrow
pulse pressure, PR of 90
bpm, ECG has atrial
fibrillation, persistent ST
segment abnormalities,
decreased QRS,
amplitude, s3 sound was
heard, s1 and s2 sounds
were softened, peripheral
pulses are diminished,
RR of 30bpm,
NURSING DIAGNOSIS:
Activity intolerance r/t
imbalance oxygen supply
evidenced by changes in
VS presence of
dysrhythmias, dyspnea,
pallor.
intolerance is due to effective nursing and record. current health status and after 8 hours of effective
swelling of legs and interventions, the evaluate effectiveness of nursing interventions, the
feet or generalized patient will be able to nursing intervention rendered. patient is able to do ADL’s but
weakness. do ADLs alone and -Monitor intake and -To evaluate the proper with minimal assistance and
Activity intolerance is to participate in self- output as order. functioning of his kidney in participate in self-care
insufficient care activities. relation to his present activities.
physiological or LTO: condition. LTO:
psychological energy After 2 days of -Assess ability to -To determine the capacity of Goal Fully met because after
to endure or complete effective nursing perform ADL. patient in doing ADL’s. 2 days of effective nursing
required or desired interventions, the -Assess physical -To know if there is any interventions, the patient is
daily activities it may patient will be able to mobility status. changes on patient’s condition able to maintain activity level
be related to factors maintain activity level specifically on physical aspect. within capabilities as
such as obesity, within capabilities as Tx: evidenced by normal vital
malnourishment, side evidenced by normal -Assist patient to do -To minimize fatigue and to signs during activity, as well
effects of medications vital signs during ADL’s evaluate his capabilities in as absence of weakness,
(e.g., -blockers), or activity, as well as doing such. pain, and difficulty
emotional states such absence of accomplishing tasks
as depression or lack weakness, pain, and -Assist to do active -To maximize full strength.
of confidence to exert difficulty range of motion
one's self. Further, the accomplishing tasks. exercise like flexing
goal in Activity of both extremities.
Intolerance is to - Promote rest and -To conserve energy
increase tolerance for comfort.
and endurance of - Document - Compromised myocardium/
activity. cardiopulmonary inability to increase stroke
response to activity. volume during activity may
Note tachycardia, cause an immediate increase
dysrhythmias, in heart rate and oxygen
dyspnea, demands, thereby aggravating
diaphoresis, pallor. weakness and fatigue
Collaborative:
- Implement graded
cardiac
rehabilitation/ activity - Strengthens and improves
program.
cardiac function under stress if
cardiac dysfunction is not
irreversible.
ASSESSMENT EXPLANATION OF OBJECTIVES NURSING RATIONALE EVALUATION
THE PROBLEM INTERVENTIONS
S: complains of
hypertension, stated that.
He is pale and with slow
capillary refill. He also
reports having dyspnea
on exertion and having
dry, hacking, non-
productive cough.
O: swelling of legs and
feet, BP is
150/100mmHg, narrow
pulse pressure, PR of 90
bpm, ECG has atrial
fibrillation, persistent ST
segment abnormalities,
decreased QRS,
amplitude, s3 sound was
heard, s1 and s2 sounds
were softened, peripheral
pulses are diminished,
RR of 30bpm, urine
output is 1mL/hr.
NURSING DIAGNOSIS:
Cardiac output decreased
r/t altered myocardial
contractility as evidenced
by increased heart rate,
dysrhythmias, ECG
changes, change in BP,
extra heart sounds,
decreased urine output,
JVD, edema.
In my nursing STO: Dx: STO:
diagnosis cardiac After 3-4 hrs of nursing At the end of 8-hour
output is decreased interventions, the client -Assessed for and nursing interventions, the
due to the low-output will be able to: document the ff: goal was partially met as
symptoms, which are * Mental Status *Cerebral perfusion is directly evidenced by:
caused by the Demonstrate r/t cardiac output and aortic
inability of the heart hemodynamic stability perfusion pressure and is PR =95%
to generate enough (blood pressure and influenced by hypoxia and
cardiac output, cardiac output)by 20%– electrolyte and acid-base Cardiac monitoring
leading to reduced 30% as revealed in the variation. revealed slight
blood flow to the cardiac monitor LTO: *Lung sounds *Crackles may develop r/t disturbance
brain and other vital At the end of 8-hour alterations in MI
organs. nursing interventions, the *Blood Pressure *Hypotension r/t LTO:
client will be able to: hypoperfusion, vagal Endorsed to the next
stimulation, dysrhythmias, or shift NOD for further
Demonstrate ventricular dysfunction may interventions and
hemodynamic stability occur. revisions of NCP for
(Blood pressure and *Heart Sounds *Bradycardia may be present continuity of care.
cardiac output) by 31%- because of vagal stimulation
80% as revealed in the or conduction disturbances r/t
cardiac monitor. area of MI.
*Urine Output *Urine output <0.5mL/kg/hr
Manifest absence of may reflect reduced renal
angina perfusion and glomerular
filtration as a result of
reduced cardiac output.
*Peripheral Perfusion *Decreased may indicate a
decreased cardiac output.
-Kept client on bed in -Facilitate oxygenation
Semi- fowler’s and
administered high flow O2
via nasal cannula.
Tx:
-Monitor serial ECG, - ST segment depression and
chest x-ray changes,
laboratory studies (BUN,
Creatinine)
-Administer medications
as indicated: diuretics,
vasodilators, ACE
inhibitors, Digoxin,
inotropic agents,
adlosterone antagonist,
anticoagulant
-Administer IV solutions,
restricting total amount as
indicated. Avoid saline
solutions.
- Encourage rest, semi-
recumbent in bed or chair.
Assist with physical care
as indicated; elevate legs,
avoiding pressure knee.
T wave flattening can develop
because of increased
myocardial oxygen demand.
Chest x-ray may show
enlarged heart and changes
of pulmonary congestion.
Elevation of BUN/creatinine
reflects kidney
hypoperfusion/failure.
-A variety of medications may
be used to increase stroke
volume, improve contractility,
and reduce congestion.
-Because of existing elevated
left ventricular pressure, client
may not tolerate increased
fluid volume.
- Physical rest should be
maintained during acute or
refractory HF to improve
efficiency of cardiac
contraction and to decrease
to myocardial oxygen
demand.