Assessment Diagnosis Planning Action Rationale Evaluation

Independent:
Subjective: Decrease After 2-3 days nursing After 2-3 days
“bumaba ng cardiac interventions the client Build harmonious rapport in To establishes trust between nursing interventions
madalas ang output will experience: client and relatives. me, client and relatives. was:
aking BP” as related to
verbalized by generalized  Diminish dyspnea IV therapy at KVO as ordered. To maintain patients hydration FULLY MET.
the client. weakness upon exertion. and maintain catheter patency by
preventing internal luminal (inner
Objective:  Remain free from surface) occlusion.
 Dyspnea pain.
upon Assess skin color, temperature, To monitor the cold, clammy,
exertion  Decrease jugular and moisture. pale skin, low cardiac output and
 Chest pain vein distention. oxygen desaturation.
 Distended
neck vein  Capillary refill Check for any alterations in To reperfusion immediately and
 Capillary within < 2 sec. level of consciousness. prevent decreased cerebral
refill perfusion and hypoxia that
>2sec.  Diminish sudden reflected in irritability,
 Paroxysma shortness of breath restlessness, and difficulty
l nocturnal during sleep. concentrating.
dyspnea
 Orthopnea  Verbalized reduce Assess heart rate and blood To have compensatory
 Peripheral fatigue. pressure. tachycardia and significantly low
edema blood pressure in response to
 Fatigue  BP and HR within reduced cardiac output.
V/S: normal range.
 BP: 140/90 To monitor weak pulses that are
mmHg Check for peripheral pulses, present in reduced stroke volume
 HR: 119 including capillary refill. and cardiac output.
bpm
To determine how often the
Record urine output.
Assess heart sounds for gallops left ventricular ejection and is a
(S3, S4).
Assess respiratory rate,
rhythm, and breath sounds.
Identify any presence of
paroxysmal nocturnal dyspnea
(PND) or orthopnea.
Assess CVP, pulmonary artery
diastolic pressure (PADP),
pulmonary capillary wedge
pressure (PCWP), as well as
cardiac output and cardiac
index.
Assess oxygen saturation with
pulse ox meter both at rest and
patient urinates to monitor if its
gain weight because renal system
counterbalances low BP by
retaining water. Oliguria is a
classic sign of decreased renal
perfusion.
To know if S3 indicates reduced
class sign of left ventricular
failure. S4 occurs with reduced
compliance of the left ventricle,
which impairs diastolic filling.
To identify shallow, rapid
respirations are characteristics of
decreased cardiac output.
CVP provides information on
filling pressures of the right side
of the heart; PADP and PCWP
reflect left-sided fluid volumes.
Cardiac output provides an
objective number to guide
therapy.
To monitor alteration in oxygen
saturation is one of the earliest
signs of reduced cardiac output.
during and after ambulation.
Check symptoms for chest
pain.
Assess for reports of fatigue
and reduced activity tolerance.
Monitor electrocardiogram
(ECG) for rate, rhythm, and
ectopy.
Provide adequate rest periods
and assist with all activities.
Position in high-Fowler’s
position.
Encourage salt restriction to 2-
3g/day.
Restrict fluid as ordered.
Teach patient the reposition
every 2 hrs.
Provide quiet environment and
therapeutic management.
To determine low cardiac output
can further decrease myocardial
perfusion, resulting in chest pain.
To guide for optimal progression
of activity.
For cardiac dysrhythmias may
occur from low perfusion,
acidosis, or hypoxia.
To reduces stress and improves
overall health and improves
focus.
To reduce preload and ventricular
filling when fluid overload is the
cause.
To reduce blood pressure and risk
of cardiogenic shock.
To avoid overloading of heart
or in bloodstream.
To help keep blood flowing skin
stay healthy and prevents
bedsores.
To help patient avoid stressful
situations, listen and respond to
expressions of feelings.
To avoid activities eliciting a

Provide bedside commode.
Avoid activities eliciting a
vasovagal response (straining
during defecation, holding
breath during position
changes).
Elevate legs, avoiding pressure
under knee.
Encourage active and passive
exercises.
Documentation
Dependent:
Administer oxygen therapy 10- carbon dioxide is removed.
15 l/min. as prescribed.
Administered medication as
prescribed:
 ACE-Inhibitors:
Digoxin (Lanoxin)
vasovagal response (straining
during defecation, holding breath
during position changes).
To help lower the pressure in
legs by allowing blood pooled to
drain away.
To prevent stiffness and regain
range of motion in muscles.
To quality and process control.
To makes sure that the body
receives adequate oxygen and that
 To relax veins, arteries
and lower the blood
pressure. Also, increases
contractility of the heart
and force of contraction.
 To improve the function

 Beta-blockers:
carvedelol
 Furosemide (Lasix); spi
ronolactone
(Aldactone)
Monitor electrocardiogram for
rate and rhythm.
Monitor results of laboratory
particularly in potassium and
diagnostic tests.
Monitor Swans-Ganz catheter.
Collaboration:
Dietician
Respiratory therapies
of the failing LV.
 To reduce extra fluid in
the body especially
decreases edema
formation and diminish
afterload.
To identify cardiac dysrhythmias
may occur from low perfusion,
acidosis, or hypoxia. Tachycardia,
and bradycardia.
To monitor hypokalemia toxicity;
hypokalemia is common in heart
patients because of diuretic use.
To monitor the heart's function
and blood flow and pressures in
and around the heart
To establish low salt and low fat
diet.
To help breathe more easily.
Assessment Diagnosis Planning Action Rationale Evaluation

Subjective: Ineffective airway After 3 days of nursing  Assess respiratory function, After nursing
“may kulay pula clearance related to interventions the client breath sounds, speed and intervention
sa kanyang the disease process will experience: rhythm. was partially
plema,” as of Tuberculosis as met and
verbalized of the evidenced by  Airway clearance back  Administered oxygen understand the
relatives of the crackles upon effectively. therapy as prescribed. disease process.
client. auscultation, RR:  Respiratory rate within
32 bpm, SpO2 level normal limits.
Objective: of 83%,  Reduce crackles  Give the patient semi-
 RR: 32 bpm hemoptysis. sounds Fowler's position or high
 (+) crackles  SpO2 within normal Fowler effectively assist the
sounds range. patient to cough and
 SpO2: 83%  Decrease Hemoptysis deep breathing exercises.
 Hemoptysis  Relieve fatigability
 Easy  Free from anorexia  Maintain fluid intake at least
fatigability  Weight gain and body 2500 ml / day, except, contra
 Anorexia wasting indications.
 Weight loss  Decrease long term
and body low- grade fever
wasting  Diminish chills and  Collaboration for the
 Persistent, night sweats administration of drugs
long term  Decline persistent, according to indications,
low- grade progressive cough. mucolytic drugs.
 fever  Know the 6 month
 Chills and rule oftreatment.  Assess Mantoux test and
night sweats  Reduce dull pain. report immediately to Dr.
 Persistent,  Manage Dyspnea ROD.
progressive  Increase nutritious  Assess spinal damage as
cough. food to alleviate evidenced by back pain and
 (+) mantoux Anemia. stiffness.
Test
 Dull pain  Monitor major organs such
 Dyspnea as kidney and liver for
 Anemia effectiveness of filtering of
blood.

 Explain the treatment

process.

 Review pathology of disease

(active and inactive phases)
and potential spread of
infection via airborne droplet
during coughing, sneezing,
spitting, talking, laughing,
singing.

 Identify others at risk like

household members, close
associates and friends.

 Instruct patient to cough or

sneeze and expectorate into
tissue and to refrain from
 spitting. Review proper
disposal of tissue and
good hand washing
techniques.

 Encourage return
demonstration.

 Review necessity of
infection control measures.
Put in temporary respiratory
isolation if indicated.

 Monitor temperature as
indicated.

 Identify individual risk

factors for reactivation of
tuberculosis: lowered
resistance associated with
alcoholism or malnutrition.

 Stress importance of
uninterrupted drug therapy.
Evaluate patient’s potential
for cooperation.

 Review importance of
follow-up and periodic
reculturing of sputum for the
 duration of therapy.

 Encourage selection and

ingestion of well-balanced
meals. Provide frequent
small “snacks” in place of
large meals as appropriate.

 Liver function studies:

AST/ALT. To monitors
adverse effects of drug
therapy including hepatitis.

 Notify local health

department.

 Administer anti-infective
agents as indicated:

Primary drugs: isoniazid
(INH), ethambutol
(Myambutol), rifampin
(RMP/Rifadin)
Second-line
drugs: ethionamide
(Trecator-SC), para-
aminosalicylate

 Identify the members of the

households whoe has contact
with the patient and
encourage to testing for
tuberculosis.
 Teach him to cough in tissue
and dispose properly.

 Educate in proper hand

washing technique and wear
a facial mask.

 Assist in isolation room to

reduce the risk of spreding
the infection in the healcare
worker as well as the
relatives.

 Facilitate Direct Observe

Therapy.

 Carry out Dr.’s order.

 Document