Nursing diagnosis

Decreased cardiac output related to post extra corporeal circulation status secondary to redged ventricular function
Impaired tissue integrity related to surgical incision as manifested by swelling around injury and local pain
Imbalanced nutrition less than body requirement related to loss of appetite, decreased intake, and anxiety as evidenced by
considerable loss of weight
Anxiety related to surgery and fear of death as manifested by restlessness, increased awakeness, and facial tension.
Knowledge deficit regarding disease process, condition, prognosis, treatment regimen as evidenced by lack of questioning and
verbalized misconception
 Nursing care plan
1
Nursing theory Subjective and Nursing Goal Planning Implementation Evaluation
applied Objective data Diagnosis
Levine’s Obj: Decreased Client Monitor Patient is under Patient pulse is
conservation Tachycardia, cardiac output maintains homodynamic continues cardiac moderate and
model weak pulse, related to extra sufficient parameter, oxygen monitor. BP came to
The challenges decreased BP, corporeal cardiac saturation, and normal.
that result in decrease the circulation status output. ECG monitoring.
energy drain are perfusion secondary to
identified that redged Assess peripheral Peripheral pulse is
the heart could ventricular pulse and skin assessing every
not pump function. temaprature and 30min.
effectively and color.
cardiac output is
not maintained Administer oxygen RR is 32/mt and
adequately. The as prescribed. patient under
nurse must have continues pulse
to take action to oxymeter monitoring.
improve the
energy Maintain good Calm and quite
conservation. environment environment
provided to the
patient.
Nursing care plan
2
Nursing theory Subjective and Nursing Goal Planning Implementation Evaluation
applied Objective data Diagnosis
Levine’s Sub: wires and Anxiety related Client Assess the level Patient is having Patient appear
conservation machine to fear of death verbalizes the and causes of fear. moderate fear after calm and
model attached with as manifested by understanding knowing about express trust in
The challenges me, what’s this restlessness- of machine Explain to the hemodynamic medical
that result in Obj: facial increased and patient about the monitoring. treatment.
energy drain is tension, poor awakeness, satisfaction of hemodynamic
identified that eye contact, facial tension prognosis monitoring and it
the client having increased is temporarily
anxiety. The questioning. monitoring.
nurse must take Check patient very Every 15min asked
action to often and assure patient about his
improve the patient that close condition, and
energy monitoring ensure monitor the vital sign
conservation. prompt treatment. changes.

Administer mild Administered

tranquilizer as diazepam 0.25mg,
needed IM as prescribed.

Establish rest Rest period is given

period between in between the
care and procedure. procedure.

Nursing care plan

 3
Nursing Subjective and Nursing Goal Planning Implementation Evaluation
theory Objective data Diagnosis
applied

Levine’s Sub: wound in Impaired Client Assess the condition of Assessed the condition of Patient’s wound is
conservation the chest region tissue wound the tissue. the wound no redness, clean
model integrity healing Assess the sign of mild pain and itching
The Obj: surgical related to properly infection, elevated present over there.
challenges incision in the surgical without body temperature and
that result in chest region. incision as infection level of comfort.
energy drain manifested Apply continues or
is identified by swelling intermittent dressing. Apply intermittent over
that the client around Discourage rubbing of the wound area.
having injury and the wound.
surgical local pain. Administer medication Advice the client to avoid
wound in as prescribed. the rubbing of the
chest region.. Instruct the patient and wound.
care giver. Advised the care giver to
Teach the patient and keep the wound clean.
caregiver pain control Instruct the client sign
measures. and symptoms of
infection such as fever
and pain.

Nursing care plan

4
 Nursing Subjective and Nursing Goal Planning Implementation Evaluation
theory Objective data Diagnosis
applied
Levine’s Sub: weakness, Imbalanced Client Assess the weight of the Patient weight is 42kgs Patient is following
conservation loss of appetite. nutrition less verbaliz patient and fat composition and not appropriate to the treatment
model than body es of the body. his height. regimen and taking
The Obj: weight is requirement measure Monitor laboratory values Monitored laboratory food without
challenges not appropriate related to loss to indicate nutritional well- values of serum that’s anorexia.
that result in to height, low of appetite, maintain being. are Hb- 11.1gm
energy drain Hb level, and lack of intake normal Encourage calorie intake Encouraged to take
is identified albumin value. of food, and body appropriate for body type dhal, egg white, yolk
that the client anxiety as weight. and lifestyle. and avoid fat foods like
weight is not evidenced by Encourage patient to be oily items mutton etc.
appropriate considerable more aware of nutritional Explained about
to his height loss of habits. importance of protein
and poor weight.. Encourage patient to take and vitamin and its
nutritional nutritious food. importance.
status. The Encourage to do exercise.
nurse have to
take care Encouraged to do
action to exercise.
improve the
energy
conservation.

Nursing care plan

5
Nursing theory Subjective and Nursing Goal Planning Implementation Evaluation
applied Objective data Diagnosis
Levine’s Sub: I could Knowledge Client Assess the level of Patient is not having Patient
conservation not understand deficit regarding verbalizes understanding of knowledge about knowledge is
model what they are disease process, understanding treatment and cardiac disease. improved and
The challenges doing to me. condition, of treatment disease. Explanation given he is following
that result in Obj: increased prognosis, regimen. Teach the patient about anatomy, treatment.
energy drain is questioning treatment and signify other physiology, signs and
identified that about regimen as about the following symptoms,
the client having procedure. evidenced by anatomy, diagnostic measures,
lack of lack of physiology of and prognostic level.
knowledge about questioning and heart, signs and Explained about the
his condition verbalized symptoms, treatment, surgery
and nurse will misconception. diagnostic and follow up care of
have to take procedures, disease condition and
action to lifestyle changes, lifestyle changes.
improve the and prognosis.
energy
conservation.