11-ncp dec. cardiac output

8/11/2019 11-Ncp Dec. Cardiac Output

1/16

VIII. PLANNING

A. NURSING CARE PLAN

Date/Shift Assessment Needs Nursing

Diagnosis

Objective of

care

Nursing Intervention Evaluation

July 23,

2013

7/3

S:

Maglisod ko

ug ginhawa

as verbalized.

O:

-Pale

conjunctiva

-With O2 @

4LPM via

nasal cannula

-Pale and dry

P

H

Y

S

I

O

L

O

G

I

C

Decreased

cardiac

output

related to

increased

vascular

resistance

Rationale:

CAD

causes

narrowing

of blood

vessels.

After 8 hours of

nursing care,

patients cardiac

output will be

improved, as

evidenced by:

-Restlessness

will not be

noted

- Increased

peripheral

pulses

- Pulse rate

Independent

1. Assessed patients

condition To

determine possible

problems

(nurseslabs.com.

July 27, 2014)

2. Monitored and

record vital signs.

For baseline data

(nurseslabs.com.

July 27, 2014)

After 8 hours of Nursing

care, goal not met as

evidenced by:

- Maglisod gihapon ko

gamay ug ginhawa, as

verbalized.

-Restlessness

-Decreased

peripheral pulses

- Decreased Pulse rate

of 50 beats per minute


2/16

55

lips

- Restlessness

- Decreased

peripheral

pulses

- Decreased

Pulse Rate

VS:

BP-120/90

mmHg

RR-20 bpm

PR-42 cpm

T-38

C

N

E

E

D

Oxyge

nation

This

condition

leads to

intense

pressure

exerted on

the walls of

the blood

vessels.

The bodys

compensat

ory

mechanis

m is to

increase

the

within normal

range

3. Encouraged

patient to verbalize

concerns.

To make

client express his

feelings

(nurseslabs.com.

July 27, 2014)

4. Encouraged

patient to change

position every two

hours. To improve

venous return

(nurseslabs.com.

July 27, 2014)

5. Reinforced low

salt and low fat diet.


3/16

56

workload

of the heart

and thus

the patient

has

decreased

cardiac

output.

(Nurses

labs.com.

July 27,

2014)

To prevent further

complications of the

disease

(nurseslabs.com.

July 27, 2014)

6. Encouraged

patient to do

relaxation

techniques. To

reduce stress

(nurseslabs.com.

July 27, 2014)

7. Encouraged

patient to engage in

diversional activities

such as chatting with


4/16

57

family and friends.

To divert attention

and help patient

lessen experienced

pain and anxiety

(nurseslabs.com.

July 27, 2014)

Dependent

8. Administered

medications as

prescribed. To

help relieve the signs

and symptoms

experienced by the

patient

(nurseslabs.com.


5/16

58

July 27, 2014)

Collaborative

9. Instructed the

watcher or any

member of the family

to lessen foods high

in salt and fat in his

diet. To prevent

further complications

(nurseslabs.com.

July 27, 2014)

10. Advised the

watcher to stay and

talk with the patient.

To help lessen the

pain and anxiety that


6/16

59

the patient is

currently feeling.

(nurseslabs.com.

July 27, 2014)


7/16

60

Date/Shift Assessment Needs Nursing

Diagnosis

Objective of

care

Nursing Intervention Evaluation

July 23,

2013

7/3

S:

Maglisod ko

ug ginhawa.

Punga kaayo

as verbalized.

Luya kaayo

akong lawas.

Kapoy ilihok,

as verbalized.

O:

-Pale

palpebral

conjunctiva

P

H

Y

S

I

O

L

O

G

I

C

N

Ineffective

tissue

perfusion r/t

Decreased

hemoglobin

concentration

in blood

The

oxygen

content of

arterial blood

is almost all

bound to hgb.

The blood

After 8 hours

of nursing

care, patient

will be able to

demonstrate

behaviors on

how to have

effective

airways, as

evidenced by:

- (-) Pale

palpebral

conjunctiva

- (-) Pale and

Independent

1. Established rapport

To gain trust and

cooperation To

determine possible

problems

(nurseslabs.com. July

27, 2014).

2. Assessed patients

condition To

determine possible

problems


27, 2014)

After 8 hours of

Nursing care, goal

partially met as

evidenced by:

- Punga gihapon,

as verbalized.

- (+) Pale palpebral

conjunctiva

- (+) Pale and dry lips

-(+) Shortness of

breath

- (-) Restlessness

-Decreased

peripheral pulses


8/16

61

-With O2 @

4LPM via

nasal cannula

-Pale and dry

lips

-Shortness of

breath

- Restlessness

- Decreased

peripheral

pulses

- Decreased

Pulse Rate

VS:

BP-120/90

mmHg

E

E

D

Oxyge

nation

vessels

cannot

adequately

produce

erythropoietin

that leads to

decrease in

Hgb and Hct

count, thus

resulting to

anemia.

Because of

this, the

patient

manifested

pale

dry lips

-Shortness of

breath not

noted

- Restlessness

not noted

- Increased

peripheral

pulses

- Pulse Rate

within normal

range

3. Monitored and record

vital signs. For

baseline data


27, 2014)

4. Encourage quiet and

restful atmosphere.

To conserve energy

and lower tissue

oxygen demands To

determine possible

problems


27, 2014)

5. Encouraged early

ambulation once

- Pulse Rate of 50

beats per minute


9/16

62

RR-20 bpm

PR-42 cpm

T-38C

Hemoglobin

count93 g/L

Hematocrit

0.29

palpebral

conjunctiva

and

paleness.

Then the

oxygen being

supplied in

the body is

not enough

due to

decrease

production of

RBC, which

are

responsible

for the

tolerated. To

enhance venous return


27, 2014).

6. Discouraged

sitting/standing for long

periods, wearing

constrictive clothing,

crossing legs. To

improve and facilitate

good circulation


27, 2014).

7.Checked for calf

tenderness. May

indicate thrombus


10/16

63

oxygenation

of tissues

thus leading

to ineffective

tissue

perfusion.

(Pathophysiol

ogy by

Bullock. Date

of retrieval:

July 27,

2014)

formation

(nurseslabs.com. July 27,

2014).

8. Instructed to avoid

strenuous activities. To

conserve energy


2014).

9. Restricted sodium,

fluid and fat intake as

indicated. To decrease

excess fluid volume


2014).

10. Regulated IVF as

ordered. To maintain


11/16

64

hydration


2014).

11. Promoted adequate

bed rest. To provide

adequate wellness


2014).

Dependent

8. Administered

medications as

prescribed. To help

relieve the signs and

symptoms experienced

by the patient



12/16

65

27, 2014)

Collaborative

11. Instructed the

watcher or any member

of the family to lessen

foods high in salt and

fat in his diet. To

prevent further

complications


27, 2014)

12. Instructed patients

watcher about food rich in

iron. To help increase

Hgb count



13/16

66

2014)

13. Advised the watcher

to stay and talk with the

patient. To help lessen

the pain and anxiety that

the patient is currently

feeling. (nurseslabs.com.

July 27, 2014)


14/16

67

Date and

Time

Assessment Need Nursing

Diagnoses

Planning Nursing interventions Evaluation

July 23, 2014

7-3

S: Malipong

ko kung

mubangon,

as verbalized.

Luya kaayo

akong lawas.

Kapoy ilihok,

as verbalized.

O:

-pale

palpebral

conjunctva

-pale and dry

lips

-needs

P

H

Y

S

I

O

L

O

G

I

C

N

E

E

Risk for injury r/t

Dizziness

R: Dizziness

may be caused

by your fever

which could be

caused by some

sort of bacteria

or virus. Your

body raises its

own temperature

to try and kill off

the bacteria or

virus as by

After 8 hours of

nursing care,

dizziness will

not be felt as

evidenced by:

- (-) pale

palpebral

conjunctva

- (-) pale and

dry lips

-do not need

further

assistance in

ambulation

-wide range of

Independent:

1. VS monitored and

recorded. R: To have

baseline data.

2. Established rapport.

R: To gain trust and

cooperation.

3. Stayed with the client

and made arrangements

to have someone else to

be there. R: To have

someone who can assist/

help during ambulation.

4. Evaluated the place

with things that could

After 8

hours of

nursing

care, goal

partially

met, as

evidenced

by:

- Wala

naman ko

nalipong, di

parehas

ganina.

Luya ra jud

ilihok, as


15/16

68

assistance in

ambulation

-limited range

of motion

VS:

BP-120/90

mmHg

RR-20 bpm

PR-42 cpm

T-38C

Hemoglobin

count93 g/L

Hematocrit

0.29

D

S

A

F

E

T

Y

A

N

D

S

E

C

raising the

temperature, the

cell of the

bacteria or the

receptors of the

virus can

become

denatured.

However due to

this rise in

temperature,

your body uses

up the fluid in

your system

quicker so that

you can become

dehydrated

motion noted

(Can sit up on

bed, turn to

sides, and

ambulate

without

assistance)

contribute to injury. R: To

modify the environment to

keep the safety.

5. Instructed the patient

to avoid sudden head

movements and any

strenuous activities. R:

This could aggravate the

dizziness felt by the

patient.

Dependent:

6. Administered

paracetamol as ordered.

R: Analgesics; for mild

pain and fever.

Collaborative:

7. Encouraged the

verbalized.

- (+) pale

palpebral

conjunctva

- (+) pale

and dry lips

-Needs

assistance

in

ambulation

-Can sit up

on bed

without

assistance


16/16

69

NANDA 2006

U

R

I

T

Y

which can lead

to the feelings of

dizziness and

light

headedness

(http://health.blur

tit.com/185895/

what-would-

cause-a-fever-

and-dizziness,

Date Retrieved:

July 27, 2014).

companions to assist

during ambulation. R: To

avoid any injuries that

could contribute to fear.

8. Instructed the watcher

not to leave the patient

alone.R: To avoid any

sudden injury.
http://health.blurtit.com/185895/what-would-cause-a-fever-and-dizzinesshttp://health.blurtit.com/185895/what-would-cause-a-fever-and-dizzinesshttp://health.blurtit.com/185895/what-would-cause-a-fever-and-dizzinesshttp://health.blurtit.com/185895/what-would-cause-a-fever-and-dizzinesshttp://health.blurtit.com/185895/what-would-cause-a-fever-and-dizzinesshttp://health.blurtit.com/185895/what-would-cause-a-fever-and-dizzinesshttp://health.blurtit.com/185895/what-would-cause-a-fever-and-dizzinesshttp://health.blurtit.com/185895/what-would-cause-a-fever-and-dizzinesshttp://health.blurtit.com/185895/what-would-cause-a-fever-and-dizzinesshttp://health.blurtit.com/185895/what-would-cause-a-fever-and-dizziness

11-ncp dec. cardiac output

Documents