ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

Risk for Decreased cardiac Short term goal Evaluate client reports and To assess for signs of poor STG met as evidenced by
Subjective output related to evidence of progressive ventricular function after 1 hr of nursing
decreased oxygenation as After 1 hr of nursing shortness of breath and/or impending cardiac intervention the patient
unable to breathe in evidenced by shortness of intervention the patient’s failure SPO2 increases to 95%.
supine position breath, use of accessory SPO2 will increased from
muscles in respiration 92% to 95%
secondary to Pneumonia Determine vital This provides a baseline
Objective Long term goal signs/hemodynamic for comparison to follow LTG met as evidenced by
irregular, shallow, parameters including trends and evaluate the patient reported
breathes through mouth After 8 hrs of nursing cognitive status. Note vital response to interventions decrease episodes of
interventions the patient signs response to activity dyspnea.
bilateral course crackles will report decreased or procedures and time
on lower lobes with episodes of dyspnea required to return to
decreased breath sounds baseline
at posterior area

CXR result reveals Review signs of impending Early detection of changes

pneumonia, failure/shock, labored
respirations, changes in
WBC at 14,000 breath sounds, distant or
altered heart sounds,
SPO2 92% with O2 edema and reduced
urinary output
in these parameters
promotes timely
intervention to limit the
degree of cardiac
dysfunction.

Keep client on bed or chair This decreases oxygen

rest in a position of consumption and the risk
comfort of decompensation

Administer oxygen via

mask or ventilator, as
indicated. To increase oxygen
available for cardiac
functioning
Encourage the client to
breathe in/out during
activities that increase risk
for the Valsalva effect

Review the ABG

Left ventricular failure is

characterized by mild
respiratory alkalosis (early)
or hypoxemia with an
increased PCO2(late).

Monitor the oxygen sat

using pulse oximetry

Oxygen saturation may be

low, especially when acute
HF is imposed on chronic
obstructive pulmonary
disease (COPD) or chronic
HF.
Case
Patient H, 4 year-old female, Filipino, born on Feb 15, 2022 in Camp 8, Baguio City was admitted on April 15, 2020 @ 10AM due to cough, fever, accompanied by nausea and
vomiting under the service of Dr. Sotto. Initial diagnosis: PCAP-C

Patient History
Born full-term via CS, 2nd out of 3 children of a Jeepney driver (35 y/o) and a housewife (33 y/o). Both parents are hypertensive and father is smoking 2 pack/day for 8 years.
Cough started 2 days prior to admission, followed by an on & off fever thereafter. Nausea and vomiting followed after giving Paracetamol as home remedy. 3 hrs prior to
admission, temperature went up to 38.8 C.
Physical Assessment
T 38.2C, PR 125bpm, SPO2 92% with 02, RR 44cpm, irregular, shallow, breathes through mouth, uses accessory muscle for breathing, unable to breathe in supine position,
audible breathe sounds within few feet. Auscultation reveals bilateral course crackles on lower lobes with decreased breath sounds at posterior area. CXR result reveals
pneumonia, , RBC & platelets normal. Stool and urine analysis is also normal.