PRINCESS Q PIMENTEL

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE: Risk for decreased After 2 hours of nursing - Monitor BP - Goal was met
cardiac output related interventions, the lying, sitting, and
Patient complains of to Uncontrolled patient will maintain standing, if able. - At the end of
nervousness, weakness, hyperthyroidism, adequate cardiac Note widened the 2 hour
and palpitations with hypermetabolic state output in accordance pulse pressure. nursing
exertion for the past 6 with the needs of the intervention, the
months. body as characterized - Monitor central patient has
 Heat intolerance by: venous pressure Maintained
 Diaphoresis (CVP), if adequate
 Nervousness  stable vital signs, available. cardiac output
and fine tremors for tissue needs
 normal
of hands
peripheral pulses, - Investigate as evidenced by
reports of chest stable vital signs,
OBJECTIVE:  normal capillary pain or angina. palpable
filling, peripheral
 Palpations,  good mental - Assess pulse and pulses, good
cardiac status, heart rate while capillary refill,
dysrhythmias,  no patient is usual mentation,
such as dysrhythmias. sleeping. and absence of
tachycardia or dysrhythmias.
atrial fibrillation.
 Protruding - Auscultate heart
eyeballs sounds,
(exophthalmos) note extra heart
is present sounds,
 Anxious development of
 Smooth, soft gallops and
 skin systolic
 Protruding murmurs.
eyeballs
(exophthalmos) - Monitor ECG,
is present noting rate and
rhythm.
V/S taken as follows: Document
dysrhythmias.
BP: 130/60
PR: 92 bpm - Auscultate
TEMP: 37.2 breath sounds.
RR: 22 cpm Note
adventitious
sounds.

- Monitor
temperature;
provide cool
environment,
limit bed linens
or clothes,
administer tepid
sponge baths.

- Observe signs
and symptoms
of severe thirst,
dry mucous
membranes,
weak or thready
pulse, poor
capillary refill,
decreased
urinary output,
and
hypotension.