Shyla Nicole C.

Manguiat 11/15/2021
3 BSN-B / NCM 112 PROF. HERMAN ZOLETA
NURSING CARE PLAN
CARDIOVASCULAR DISEASES

HEART FAILURE

PLANNING
ASSESSMENT NURSING EVALUATION
DIAGNOSIS GOAL/EXPECTE NURSING RATIONALE
D OUTCOME INTERVENTION

Objectives: Decreased Short Term Goal: 1. Assess heart 1. Peripheral pulses Goal is
cardiac output sounds, VS, peripheral and capillary refills partially met,
pulses, capillary refill. may be weak with
heart murmurs related to 1. Patient will be
reduced stroke
as auscultated chronic heart free from crackles Patient able to
volume and cardiac
failure in lungs by output. cough up
decreased secondary to adequately 2. Assess for breath secretions
activity rheumatic coughing up sounds. 2. Crackles reflect adequately.
intolerance heart disease secretions during accumulation of fluid Pulmonary
as evidenced the shift. in pulmonary crackles not
circulation. auscultated in
fatigue by heart
3. Assess the weight,
murmurs, 2. Patient will get bases of
skin color and 3. Weight is an
decreased decreased out of bed at least temperature, urinary indication of fluid lungs. Patient
urinary output activity 3x as tolerated output. retention. is also
intolerance during the shift. responding
dyspnea and 4. Monitor serum well from the
crackles Long Term Goal: electrolytes and 4. Hyponatremia and medications
digitalis level. hypochlorite are and waiting for
causative factors for
1. After surgery, the surgery.
diuretic use.
patient maintains 5. Administer
adequate cardiac ampicillin-sulbactam, 5. Ampicillin for
output as evidence captopril, pneumonia. Captopril
by strong chlorothiazide, for reducing BP and
digoxin, furosemide. decreasing workload
peripheral pulses,
(as prescribe by the of heart.
BP within normal physician) Chlorothiazide and
range for age, furosemide to reduce
urinary output >30 circulating volume,
ml/hr, warm and enhance sodium and
dry skin, eupnea water excretion, and
with absence of improve symptoms.
Digoxin to improve
pulmonary
myocardial
crackles by contractility.
discharge
6. Encourage low salt
intake.

7. Mitral valve surgery

scheduled for
11/16/21.

8. Start patient on
ferrous sulfate as
prescribed by the
physician. Hgb 10.5
g/dL and Hct 33.6%.

9. Assist the patient

with ambulation in
slow progression as
tolerated.

10. Continue droplet

precautions for
pneumonia as
ordered.
CONGESTIVE HEART FAILURE

PLANNING
ASSESSMEN NURSING GOAL/EXPECTE NURSING RATIONALE EVALUATION
T DIAGNOSIS D OUTCOME INTERVENTION

Objectives: Activity Short Term Goal: Independent: Goal met, The

intolerance patient
1. Assess 1. To check if it verbalized her
Pallor skin related to After 8 hours of
patients is quite fearful
color reduced nursing confidence
readiness to of overexerting
cardiac intervention the increase activity their hearts or with
Weak looking output as patient will causing progressive
evidenced verbalize discomfort. activity.
Vital signs by pallor confidence with
taken: skin progressive 2. For in patients 2. A saturation
monitor oxygen of greater than
activity.
saturation 90mmHg
BP: 90/70 recommended.
PR: 42 Long Term Goal:
3. Encourage 3. An honest
After the period of verbalization of rapport
hospitalization, the feelings facilitates
patient will regarding problem
exercise or need solving and
continue to
to increase successful
verbalize activity coping.
confidence with
progressive activity 4. Inform patient 4. May improve
at home. about health mortality (w/
benefits and long term
physical effects exercise)
of activity or
exercise

5. Instruct 5. Information
patient regarding enables patient
whom to call if to take control
any abnormal of situation.
response to
exercise is
noted.

6. Teach patient 6. HR is a
to self-monitor guide for
their pulse rate if monitoring
appropriate. intensity or
duration of
exercise.
 PLANNING
ASSESSMEN NURSING GOAL/EXPECTE NURSING RATIONALE EVALUATION
T DIAGNOSI D OUTCOME INTERVENTION
S

Subjective: Acute pain After 8 hours of Independent: Goal met,

related to nursing after 8 hours
1. Assess 1. To assist in of nursing
“ang sakit ng decreased intervention the
patient pain for accurate
leeg ko pati myocardial patient will: intervention
intensity using a diagnosis.
kaliwang braso blood flow pain rating scale, the patient
ko at likod at as 1. Remain free location, and was free from
para akong evidenced from pain precipitating pain, maintain
may heartburn” by chest factors. stable vital
as verbalized pain 2. Maintain stable signs and
2. Monitor vital 2. To check if it relaxed body
by the patient vital signs
signs, especially reflects
posture.
pulse and blood compensatory
Objective: 3. Maintain relaxed pressure, every mechanisms
body posture 5 minutes until secondary to
Chest pain pain subsides. sympathetic
nervous system
Tachycardia stimulation.

Elevated blood 3. Provide 3. To provide

comfort non-
pressure
measures. pharmacological
pain
Jugular vein management.
distention
4. Elevate the 4. Elevation
Cool and head of the bed. improves chest
clammy skin expansion and
oxygenation.

5. Teach patient 5. To promote

relaxation relaxation
techniques and
how to use them
to reduce stress.

6. Administer or 6. It reduces the

assist with self- amount of blood
administration of returning to the
vasodilators, as heart,
ordered. decreasing
preload,
decreasing its
workload.
 PLANNING
ASSESSMENT NURSING GOAL/EXPECTE NURSING RATIONALE EVALUATION
DIAGNOSIS D OUTCOME INTERVENTION

Subjective: Ineffective After 8 hours of Independent: Goal met,

Breathing nursing after 8 hours
1. Establish 1. To gain of nursing
“nahihirapan Pattern intervention,
rapport comfort feelings
ako huminga at related to patients respiratory intervention
from the patient
medyo nahihilo decreased pattern will be the patients
ako” as lung effective without 2. Monitor and 2. To gain airway
verbalized by expansion causing fatigue record vital signs baseline data breathing is
the patient as To gain baseline cleared
evidenced data
Objective: by
3. Inspect thorax 3. It determines
tachypnea for symmetry of adequacy of
Facial
respiratory breathing
grimacing movement

Weakness 4. Observe 4. It will identify

breathing pattern increased work
Productive for SOB, nasal of breathing.
cough flaring, pursed lip
breathing or
Pursed lip prolonged
expiratory phase
breathing and use of
accessory
Tachypnea muscles

5. Measure tidal 5. It will indicate

volume and vital the volume of
capacity air moving in
and out of the
lungs

6. Assess 6. It detects the

patients’ use of
emotional hyperventilation
response as a causative
factor

7. Assist patient 7. It reduces

to use relaxation muscle tension,
techniques decreases work
of breathing

8. Position
patient in optimal
body alignment
in semi- fowler’s
position for
breathing.
 PLANNING
ASSESSMEN NURSING GOAL/EXPECTE NURSING RATIONALE EVALUATION
T DIAGNOSI D OUTCOME INTERVENTION
S

Objective: Impaired Short Term Goal: Independent: Goal met,

Gas patient
Facial Patient will 1. Position the 1. It enhance demonstrates
Exchange
Grimacing demonstrate a patient in a High expectoration of
related to normal depth,
normal depth, rate, Fowler’s position secretions to
altered with the head of improve rate, and
and pattern of
BP - 130/90 oxygen the bed elevated ventilation. pattern of
respirations.
supply as up to 90°. respirations
PR – 93%
evidenced Long Term Goal: and maintain
by coughing 2. Keep patients 2. To avoid optimal gas
Coughing back dry. coughing
Patient will exchange.
maintain optimal
Restlessness 3. Promote 3. Rest will
gas exchange
adequate rest prevent fatigue
Shortness of periods and decrease
breath oxygen
demands for
metabolic
demands

4. Keep the 4. To reduce

environment irritant effects
allergen-free on airways

5. Suction 5. To clear the

secretions PRN airway when
secretions are
blocking the
airway.

6. Administer 6. It improves,
oxygen therapy oxygen is
as ordered. titrated to
maintain pulse
oximetry
readings greater
than 92%.

7. Administer 7. Diuretics
diuretics as promote
ordered. normovolemia
by decreasing
fluid
accumulation
and blood
volume.

8. Have airway 8. A likelihood

emergency of cardiac arrest
equipment for patients with
available at the severe
bedside. decompensated
heart failure.