NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE: Risk for decreased Cardiac After 24 hours, the patient INDEPENDENT: After 24 hours, the patient
Output related to Cardiac will display hemodynamic Identify clients exhibiting displays hemodynamic
The patient verbalized, arrhythmia as evidence by stability. symptoms or at risk as stability.
“Sumasakit po ang aking chest pain, fatigue, noted in Related/Risk
dibdib, madalas rin po weakness, dizziness, and Factors and Defining
akong nakakaramdam ng altered hemodynamic Characteristics.
pagkapagod…kasabay po stability.
ng aking panghihina at
pagkahilo.”
OBJECTIVE: Determine vital signs/
Respiratory Rate: 30 hemodynamic parameters
Pulse Rate: 114 including cognitive status.
Blood Pressure: 140/110
mmHg

Cool and clammy skin

Perform periodic
hemodynamic
measurements, as
indicated.
Monitor cardiac rhythm
continuously.
Provide adequate fluid/
free water, depending on
clients need.
Provide a quiet
environment.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Assist with or perform self-

care activities for client.
DEPENDENT:
Review laboratory data
and diagnostic studies.
Administer medications,
such as diuretics, inotropic
drugs, anti-steroids,
vasopressors, and/or
dilators , as appropriate,
and monitor cardiac
responses.
Restrict or administer
fluids (IV/PO), as indicated.
Use sedation and
analgesics, as indicated.
 NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE: Deficient knowledge regarding After an hour, the Review laboratory data and After an hour, the patient
medical condition and therapy patient will verbalize diagnostic studies. verbalized his/her
The patient verbalized, needs related to lack of information knowledge of the knowledge of the disease
“Sumasakit po ang aking resources evidenced by questions, disease process, process, individual risk
dibdib, madalas rin po statement of misconception, failure individual risk factors, factors, and treatment
akong nakakaramdam ng to improve on previous regimen, and treatment plan. plan.
pagkapagod…kasabay po and development of preventable
ng aking panghihina at complications.
pagkahilo.”
OBJECTIVE: After an hour, the Discuss the individual's After an hour, the patient
Respiratory Rate: 30 patient will be able to is able to identify signs of
Pulse Rate: 114 identify signs of particular risk factors for cardiac decompensation,
Blood Pressure: 140/110 cardiac management of identified risk alter activities, and seek
mmHg decompensation, alter help appropriately when
activities, and seek factors. needed.
Cool and clammy skin help appropriately
when needed.

Provide information to clients/

caregivers on individual
condition, therapies, and
expected outcomes.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Educate client/caregivers
about drug regimen, including
indi-cations, dose and dosing
schedules, potential adverse
side effects, or drug/drug
interactions.

Provide instruction for home

monitoring of weight, pulse,
and blood pressure, as
appropriate.

Discuss significant signs/

symptoms that need to be
reported to healthcare
provider, such as unrelieved or
increased chest pain,
dyspnea, fever, swelling of
ankles, and sudden
unexplained cough.

Emphasize the importance of

regular medical follow-up care.