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Nursing Care Plan: Assessment Diagnosis Goal Planning Rational Objective Data
Nursing Care Plan: Assessment Diagnosis Goal Planning Rational Objective Data
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.
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.
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.
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.
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. .
HEALTH EDUCATION :
Medication
Diet
Provide healthy foods including fruits, vegetables, low fat dairy products.
Wound care
Observe incision site for signs of redness, swelling, tenderness, warmth or drainage.
Lifestyle
Vaccination
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.
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