Far Eastern University

Institute of Nursing

Nursing Care Plan

Nursing Diagnosis Analysis Goal and Interventions Rationale Evaluation
Objectives

Decreased cardiac Heart failure, After 8 hours of After the

output related to also called Nursing nursing
altered myocardial congestive intervention the intervention
contractility heart failure, patient will the patient
/inotropic changes occurs when display vital signs was able to
as manifested by cardiac output is within acceptable display vital
tachycardia/dysrhy inadequate to limits, signs within
thmias. meet the dysrhythmias acceptable
metabolic controlled and no limits,
SUBJECTIVE: demands of the symptoms of dysrhythmia
body. The heart failure. s controlled
The client verbalized rate increases and no
that “minsan as a Objectives: symptoms of
nahihirapan ako compensatory After the nursing  Auscultate  Tachycardia failure. The
huminga at mabilis mechanism to intervention, the apical is usually goal was
ako mapagod”. increase cardiac client will be able: pulse; present even met.
output, and assess at rest to
“Minsan ay sumasakit vasoconstriction a. To display heart rate, compensate
din ang ulo ko at occurs to try to hemodynami and for decreased
nahihilo”. maintain blood c stability. rhythm. ventricular
pressure. contractility.
OBJECTIVE: Eventually, the
chronic increase  Pallor is an
 Cool, clammy in preload and  Inspect skin indicative of
skin after load for pallor, diminished
 (+) Fatigue contributes to cyanosis. peripheral
 (+) Shortness chamber dilation perfusion
of breath and secondary to
hyperthrophy, inadequate
Measurement: worsening heart cardiac
failure. output,
Underlying
RR = 26cpm causes of heart vasoconstricti
CR = 112bpm failure include on, and
TEMP = 36.2°C congenital heart anemia.
BP = 140/80mmHg disease, Cyanosis may
rheumatic develop in
heartdisease, refractory
endocarditis, heart failure.
myocarditis, and Dependent
non areas are
cardiovascular often blue or
causes such as, mottled as
chronic venous
pulmonary congestion
disease, various  Monitor increases.
metabolic urine
diseases, and output,  Urine output
anemia. noting is usually
Complications of decreasing decreased
heart failure output and during the
include dark or day because
pneumonia, concentrate of fluid shifts
pulmonary d urine. into tissues
edema, but may be
pulmonary increased at
emboli, night because
refractory heart fluid returns
failure, and to circulation
myocardial b. Demonstrate when patient
failure. an increase  Note is recumbent.
in activity changes in
tolerance. sensorium.  May indicate
inadequate
cerebral
perfusion
secondary to
decreased
cardiac
 Provide output.
quiet
environmen  Psychological
t. rest help
 reduce
emotional
stress, which
c. Participate in can produce
activities that vasoconstricti
reduce the on, elevating
workload of BP and
the heart. increasing
 Administer heart rate or
supplement work.
al oxygen
as  Increases
indicated. available
oxygen for
myocardial
uptake to
combat
 Administer effects of
diuretics as hypoxia or
prescribed. ischemia.

 Diuretics, in
conjunction
with
restriction of
dietary
sodium and
fluids, often
lead to
clinical
improvement
in patients
with heart
failure.