ASSESSMENT NURSING PLANNING EVALUATION

DIAGNOSIS OBJECTIVE OF INTERVENTION RATIONALE

CARE
SUBJECTIVE Decreased cardiac SHORT TERM: INDEPENDENT: PARTIALLY MET
DATA: output related to Auscultated apical Tachycardia is
alteration in the After 8 hours of pulse and assess heart usually present, even After 8 hours of
“Grabe akon heart rate as nursing intervention rate. at rest, to nursing intervention
palpitations nga evidenced by the patient will be compensate for the patient able to:
nabatyag kag ga irregular HR 130 able to report decreased
pin-ot akon bpm, and abnormal decreased episodes ventricular Reported decreased
dughan” as ECG result of heart palpitations contractility. episodes of heart
verbalized by the and angina and Premature atrial palpitations as
patient. avoid activities that contractions (PACs), evidenced by HR: 75
increases cardiac paroxysmal atrial bpm; BP 100/70
OBJECTIVE workload. tachycardia (PAT), mmHg.
DATA: PVCs, multifocal
LONG TERM: atrial tachycardia Diminished angina
HR: 130 bpm (MAT), and AF are
BP: 100/60 mmHg After 4-8 days of common Recognized and
Weak or diminished nursing intervention dysrhythmias avoided activities
peripheral pulses the patient will be associated with HF, that increases cardiac
ECG result: Sinus able to: although others may workload.
Tachycardia also occur.
Display vital signs
within acceptable Palpated peripheral Decreased cardiac
limits, dysrhythmias pulses. output may be
absent or controlled, reflected in
and no symptoms of diminished radial,
failure, for example, popliteal, dorsalis
hemodynamic pedis, and post-tibial
parameters within pulses. Pulses may
acceptable limits. be fleeting or
irregular to
 palpation, and pulsus
alternans may be
present.

Note changes in May indicate

sensorium, for inadequate cerebral
example, lethargy, perfusion secondary
confusion and to decreased cardiac
disorientation. output.

Keeping an intake and To maintain

output record to appropriate fluid
identify a negative balance
balance (more output
than input)

Encouraged rest, semi Physical rest should

recumbent in bed or be maintained during
chair. Assist with cardiac
physical care, as dysrhythmias to
indicated. improve efficiency
of cardiac
contraction and to
decrease myocardial
oxygen consumption
and workload.

Provide quiet Physical and

environment, explain psychological rest
medical and nursing helps reduce stress,
management, help which can produce
client avoid stressful vasoconstriction,
situations, listen and elevating BP and
respond to expressions increasing heart rate
of feelings or fears. and work.

Educate the patient on Providing education

home self-care. for patients will
allow them to
understand the
pathophysiology of
what is occurring in
regards to their
health. Education
will also assist
patients in
understanding
measures they can
take at home to
improve their
cardiac health and
prevent further
deterioration.

Educate patient to These maneuvers

avoid Valsalva can put extra strain
maneuvers. on the cardiac
muscle.
DEPENDENT

Administered Increases available

supplemental oxygen oxygen for
@ 2lpm via nasal myocardial uptake to
cannula. combat effects of
hypoxia and
ischemia.

Administered
medications such as:

AMIODARONE drip Primarily treats and

@21 ugtts/min. prevents ventricular
dysrhythmias.

NOREPINEPHRINE A vasoconstrictor
drip drip @15 that predominantly
ugtts/min stimulates α1
receptors to cause
peripheral
vasoconstriction and
increase blood
pressure.

CLOPIDOGREL A thienopyridine
75mg/tab derivative, binds
specifically and
irreversibly to the
platelet P2RY12
purinergic receptor,
inhibiting ADP-
mediated platelet
 activation and
aggregation

TRIMETAZIDINE Reduce the

35mg/tab expression of atrial
natriuretic peptide
(ANP) (Morgan et
al., 2006), increase
left ventricular high-
energy phosphate
levels (Fragasso et
al., 2006b), and
reduce the risk of
arrhythmias in heart
failure (Gunes et al.,
2009b; Cera et al.,
2010).
 ASSESSMENT NURSING PLANNING EVALUATION
DIAGNOSIS OBJECTIVE OF INTERVENTION RATIONALE
CARE
SUBJECTIVE Ineffective tissue SHORT TERM: INDEPENDENT: GOAL MET
DATA: perfusion related
to outflow After 8 hours of Provide rest periods Constant activity After 8 hours of
obstruction nursing between care activities and can further nursing intervention
"Nagsinuka ako. secondary to sinus intervention the prevent duration of increase ICP by the patient able to:
Tapos ga pin-ot tachycardia patient will be able procedures. creating a
dughan ko” as to demonstrates cumulative Demonstrated
verbalized by the evidenced by adequate tissue stimulant effect. adequate tissue
patient. elevated HR, perfusion as perfusion and
clammy skin, and evidenced by: Assist with position Gently repositioning reported absent of
OBJECTIVE nausea. changes. patient chest pain.
DATA: from a supine to
Warm and dry skin sitting/standing
BP: 100/60 mmHg position can reduce
HR: 130 bpm Absence of chest the risk for
ECG RESULT: pain orthostatic BP
SINUS changes.
TACHYCARDIA LONG TERM: .
Clammy skin DEPENDENT
After 2-3 days of
nursing Administer oxygen @ To increase oxygen
intervention the 2lpm via nasal cannula as available for cardiac
patient will be ordered. function.
able to:

Engage in Administer PNSS @ 60 Sufficient fluid

behaviors or cc/hr. intake maintains
actions to enhance adequate filling
tissue perfusion and pressures and
will display optimizes cardiac
increasing output needed
tolerance to for tissue perfusion.
activity.

Administer Metoprolol Beta-blockers are

50mg/tab also used for
symptomatic relief
of angina and
prevention of
ischemic events.
These agents work
by reducing
myocardial oxygen
demand, heart rate,
and myocardial
contractility.
 ASSESSMENT NURSING PLANNING EVALUATION
DIAGNOSIS OBJECTIVE OF INTERVENTION RATIONALE
CARE
SUBJECTIVE Acute pain related SHORT TERM: INDEPENDENT: GOAL MET
DATA: to reduced .
blood supply to the After 8 hours of Provide measures to It is preferable to After 8 hours of
heart nursing relieve pain before it provide an analgesic nursing intervention
"Kabatyag gid ko muscle secondary intervention the becomes severe. before the onset of the patient able to:
grabe nga palpitate to sinus patient will be able pain or before it
kag pin-ot dughan. tachycardia to: becomes severe Verbalized relief and
Tapos sa gamay lang which causes when a larger dose methods that
nga ubra gina kapoy irregular heart Report that pain or may be required. provides relief.
ko” verbalized by the beat as discomfort
patient. evidenced by is alleviated or Instruct client to report Delays in reporting
abnormal HR, controlled and pain immediately. pain
OBJECTIVE BP and hinders pain relief
DATA: verbalization of Verbalize and may
chest pain. methods that necessitate
BP: 100/60 mmHg provide relief. increased dosage
HR: 130 bpm of medication to
ECG RESULT: LONG TERM: achieve
SINUS relief. In addition,
TACHYCARDIA After 2-3 days of severe pain
nursing may induce shock
intervention the by
patient will be stimulating the
able to: sympathetic
nervous system,
Display relaxed thereby
manner; be creating further
able to sleep or rest damage and
and interfering with
engage in desired diagnostics
activity. and relief of pain.

Assist or instruct in Helpful in

relaxation techniques, such decreasing
as deep, slow breathing perception of or
and distraction. response to
pain. Pro vides a
sense of having
some control over
the situation,
increase in positive
attitude.

DEPENDENT

Administer oxygen @ Increases amount of

2lpm via nasal cannula as oxygen available for
ordered. myocardial uptake
and thereby may
relieve discomfort
associated
with tissue
ischemia.

Administer Analgesic, To reduce severe

such as morphine pain, provide
sulfate sedation, and
decrease
myocardial
workload
 ASSESSMENT NURSING PLANNING EVALUATION
DIAGNOSIS OBJECTIVE OF INTERVENTION RATIONALE
CARE
SUBJECTIVE Risk for infection SHORT TERM: INDEPENDENT: GOAL MET
DATA: related to Phlebitis
Secondary to the After 8 hours of Discontinue infusion and A proactive After 8 hours of
"Masakit akon IV Insertion of a nursing remove catheter measure to prevent nursing intervention
site” verbalized by the Peripheral Venous intervention the further damage to the patient able to:
patient. Catheter patient will be able the vein, reduce
to: pain and Verbalized comfort
OBJECTIVE DATA: discomfort, and experience
Recognize the minimize the risk of relief of pain.
 Warmth, signs and infection, and
Redness and symptoms of support the patient's VIP score: 0
Inflammation phlebitis, including overall recovery.
redness, swelling,
 Discomfort at tenderness, and
access site warmth at the IV Disinfect the access site. Proper disinfection
site reduces the risk of
introducing bacteria
Avoid unnecessary or other pathogens
movement of the into the
catheter bloodstream
through the IV line.
Infections related to
IV access sites can
lead to serious
complications,
including sepsis,
which is life-
threatening.

‘
Apply pressure to removal Help prevent or
site to prevent bleeding. minimize the
formation of
hematomas,
reducing pain and
discomfort for the
patient and the risk
of complications.

Apply intermittent warm, Heat therapy can

moist heat for 20 minutes enhance tissue
TID elasticity, making it
easier for the
affected area to
move. This is
particularly useful
in conditions
involving scar
tissue or adhesions.

Document the To provide a

observations, comprehensive and
interventions, resident’s continuous account
response and outcome in of a resident's
resident’s medical chart. health status and
care. Documenting
observations and
interventions
ensures that all
healthcare providers
have access to the
same information,
enabling them to
make well-informed
decisions and
provide consistent
care.