Name of Patient: Patient X Age: 79-years-old Sex: Male Chief complaint: Episodic shortness of breath for 2 weeks

Physician: Dr. Generalao Date of Admission: September 5, 2023 Civil Status: N/A Room: 303

DATE AND NURSING GOALS & NURSING RATIONALE EVALUATION

TIME/CUES DIAGNOSIS OBJECTIVES INTERVENTIONS

September 5, Decreased After the 8 hours INDEPENDENT INDEPENDENT

2023 Cardiac span of care: 1. Review 1. To identify imbalances, disease September 5, 2023
(8:00am) Output related laboratory processes, and desired adverse (4:00pm)
to impaired SHORT TERM data/diagnostic effects of treatments. “Partially Met”
Subjective: contractility GOAL: data (CBC,
secondary to ● Verbalize Electrolytes, After the 8 hours span
congestive knowledg ECG, X-ray, of care:
Objective: heart failure e of the Abdomen
● Shortne disease ultrasound, SHORT TERM
ss of Scientific process, Echocardiogra ● Patient’s family
breath Basis: risk m) verbalized the disease
● O2 Decreased factors, 2. Assess and 2. To provide a baseline for comparison process “Factor sad diay
saturati Cardiac and monitor vital to follow trends and evaluate ang weight gain ani
on: Output is the treatment signs, including response to interventions. maong maglisod na ug
90% inadequate plan blood pressure, pump iyang heart bantog
● Respira blood pumped ● Stabilize heart rate, pud maglisod sya
tory by the heart to O2 respiratory rate, ginhawa unya naga
rate: meet the saturation and oxygen hupong sya”
28cpm metabolic and saturation. ● O2 saturation is now
● S4 demands of respirator 3. Keep the client 3. Semi-fowler’s position decreases 93% which has improved
heart the body. y rate on bed rest and oxygen consumption and the risk of but still not on normal
sound When a ● Report elevate the bed decompensation. level. Respiratory rate is
auscult patient has decrease in a position of now 23 cpm.
ated congestive d comfort ● The patient can now talk
● Ballooni heart failure, episodes (semi-fowlers) slowly with minimal
ng belly your heart of 4. Assess and 4. This helps guide fluid and diuretic shortness of breath or
● Grade 2 can’t pump dyspnea document the therapy and maintain optimal fluid dyspnea.
edema enough blood or patient's fluid balance. To minimize dehydration and ● Medication such as
 on to supply your shortness intake and dysrhythmias. metoprolol, furosemide,
lower body’s normal of breath output to and medication that
extremit demands. ● Administe monitor for fluid lowers highblood
ies Mild r retention or pressure such as
● Weight enlargement prescribe depletion lisinopril, lozartan are
gain 8 of the left d 5. Elevate legs 5. It limits venous stasis, improves administered.
to 10 ventricular medicatio when in sitting venous return and systemic
pounds cavity, which ns position circulation, and reduces the risk of
in the has risk 6. Encourage thrombophlebitis. LONG TERM
previou factors of LONG TERM changing 6. To reduce the risk of orthostatic ● Medications and
s6 diabetes, GOALS: positions slowly hypotension, especially if heart failure treatment management
weeks obesity, and ● Ensure and dangling is present. are consistent and the
● Mild sedentary consistent legs before patient is still following
enlarge lifestyle, loses medicatio standing. the treatment plan and
ment of the ability of n proper positioning.
left the heart to managem DEPENDENT: DEPENDENT: ● Input and Output of
ventricl pump blood. ent 7. Administer 7. Inotropic drugs maintain systemic patient is being
e cavity In reaction, ● Dietary medications as perfusion and preserve end-organ monitored, patient did
● Small- blood and and Fluid ordered by the performance, diuretics reduce not developed
modera fluids collect Managem physician congestion by improving urinary dehydration and fluid
te in your lungs ent (inotropic, output. imbalance
bilateral and legs over ● Activity diuretics etc) ● Patient and the patient’s
pleural time causing that 8. Administer 8. To increase oxygen available for family participates in
effusion edema on reduces supplemental cardiac function/tissue perfusion. activities such as a
lower workload oxygen at 4 balanced diet, staying
extremities, of the L/min as per hydrated, maintaining
pleural heart doctor's order healthy weight, avoiding
effusion, thus 9. Dietary 9. Provide education on a heart-healthy, heavy activities and
decreasing changes such low-sodium diet to help manage fluid promoting bed rest.
cardiac output as low salt low retention and blood pressure.
and shortness fat as per
of breath. doctor’s order

COLLABORATIVE: COLLABORATIVE: Mary Alliza De Polonia

10. Collaborate with 10. Dietitians can help patients manage Student Nurse
a registered sodium intake, fluid restriction, and
dietitian to achieve a heart-healthy diet.
assess the
patient's
nutritional
status and
develop a
customized
dietary plan.
11. Work with 11. Collaboratively assess and respond to
telemetry changes in the patient's rhythm, as
 technicians and arrhythmias can worsen cardiac
cardiologists to output.
provide
continuous
cardiac
monitoring for
the patient.
12. Collaborate with 12. Essential for improving patient
the patient and outcomes, enhancing their quality of
their family life, and reducing the overall burden of
about heart this condition.
failure
management,
medications,
lifestyle
modifications,
and symptom
recognition.

REFERENCES:

Doenges, M., Moorhouse, M.F., & Murr, A. (2022). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales. F.A Davis
Company.