Rank Identified Cues Justification

PRIORITIZATION
Problem
1 Decrease Subjective: Heart failure is a physiologic state in
cardiac The son of the client verbalized the which the heart cannot pump to meet
output following: to meet the metabolic needs of the
related to body as determined by oxygen
heart -“ Minsan nanginginig si tatay tapos consumption by Joyce Black.
failure nilalamig at hirap na din siyang magsalita. According to Maslow’s hierarchy of
May nararamdaman din siyang hilo.” needs, oxygen is [part of physiologic
-“Nahihirapan din siyang huminga at parang needs that is vital for human survival
may kabog sa kaniyang dibdib.” and must be given prompt
interventions. It is the prioritized
- “Mukha ring matamlay si tatay na parang problem because a decreased cardiac
may dinadalang problema.” output can result to several effects
such as chest pain, skin pallor,
Objective: hypotension, diaphoresis, nausea,
agitation and a decrease of level of
-dysrrythmia consciousness and more adverse
-bradycardia effects such as ineffective tissue
-jugular vein distention perfusion, coronary artery disease,
-generalized edema accompanied with pain ischemia and eventually death. If
this problem will be managed
-cold clammy skin accordingly, it will alleviate the
-prolonged capillary refill client’s situation and it will improve
-decrease peripheral pulse (49 bpm) her condition. Thus, resolving this
-variations in blood pressure reading problem will result to the solution of
BP: 100/70 mmHg, 80/60 mmHg other identified problem. In
-presence of crackles and wheezing sound addition, it is a geriatric case so
-oliguria: 60 ml of urine with presence of vulnerability of the client should also
blood tinge for 8 hours be considered.
-paleness
-orthopnea 38cpm
- presence of S3 sound
-restlessness
-weakness
-body malaise
-dry buccal mucosa
-dry skin folds
-dry pale lips
2 Excess -generalized edema accompanied with pain It is the second problem to be
fluid -orthopnea 38cpm prioritized because it affects the
volume -oliguria: 60 ml of urine with presence of blood circulation within the body
related to blood tinge for 8 hours which is an effect of heart failure
decrease -crackles causing decreased cardiac output.
cardiac -Dyspnea Fluid accumulation suggests poor
output -RR= 38cpm circulation. Therefore, cardiac
output should be corrected in order
to increase circulation.
3 Impaired -crackles It is the third problem to be
gas -pallor prioritized because alveoli fluid
exchange -Dyspnea filling is secondary to decreased