NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE

Objective: Decreased Short term: Independent:
-ECG: Atrial cardiac output After 8 hours of 1. Monitor blood 1. Clinical indicators of the
Fibrillation related to nursing pressure, apical adequacy of cardiac
-BP: 130/90 increased atrial intervention, the pulse, peripheral output. Monitoring
-weak radial pressure and patient reports pulses enables early
pulse venous decreased detection/treatment of
-jugular vein congestion as episodes of decompensation
distention manifested by dyspnea, angina 2. Monitor cardiac
variations in and rhythm as 2. Dysrhythmias are
hemodynamic dysrhythmias. indicated. common in patient with
parameters, rheumatic heart
dysrhythmia, Longterm: disease. Atrial
dyspnea, and After 3 days of dysrhytmia is most
jugular vein nursing common, due to
distention intervention, the increased atrial
patient would pressures and volumes.
demonstrate Conduction
increased activity abnormalities also occur
tolerance and with aortic valve
participate in disease because of
activities that 3. Promote bedrest decreased coronary
reduce cardiac with head of the artery perfusion.
workload. bed elevated to
45 degrees 3. Reduces blood volume
returning to the
heart(preload), which
increases oxygenation,
decreases dyspnea, and
may reduce cardiac
strain.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE
4. Assist with activities 4. Gradual resumption of
as indicated such as activities prevents
walking overtaxing cardiac
reserves.

5. Provide routine 5. Helps redirect attention

comfort measures and promotes
e.g. shower/bath, relaxation, enhancing
back rub, position coping abilities.
change

Collaborative:
6. Administer
supplemental 6. Provides optimal
oxygen as indicated. oxygen for myocardial
uptake in an attempt to
compensate for
increasing oxygen
demand. Alterations in
myocardial circulation
7. Administer affect oxygenation and
medications as may result in increased
indicated. cardiac workload.
a. Antidysrhythmics 7. A
a. Treatment of atrial
dysrhythmia is
specific to
underlying condition
 and
symptomatology,
but is aimed at
sustaining/enhancin
g cardiac
efficiency/output.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE
b. Vasodilators d. Vasodilators are
used to decrease
hypertension by
reducing systemic
vascular resistance
(afterload). This
reduces
regurgitation and
outflow resistance.
c. Diuretics
e. Diuretics decreases
circulating volume
(preload), which
reduces blood
pressure across
dysfunctional valve,
thereby improving
cardiac function and
reduces venous
congestion.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE
Subjective Data Altered comfort; After 8 hours of INDEPENDENT
“Masakit and Acute pain r/t nursing 1. assess causative 1. To determine
dibdib ko.”, as disease process interventions, the factor for pain underlying cause of
verbalized by patient will be including location, pain because it is
the patient relieved of signs and characteristics, subjective and treat
BACKGROUND symptoms of pain onset, duration, accordingly.
Objective Data: KNOWLEDGE: experienced as frequency, quality,
 facial evidenced by: intensity and
grimace Acute pain is precipitating factors
 restl defined as an • Verbalization (with rheumatic
essness unpleasant of relief of heart disease,
 guar sensory and pain positive pain at lower
ding emotional extremities
behavior experience • Use of especially in joints)
 VAS: arising from relaxation 2. assist patient in
6 actual or skills and 2. evaluate client’s evaluating impact of
potential tissue diversional response to pain and pain on client’s life
 BP:
damage or activities as rate from 0-10 pain
130/90
described in indicated for scale
 RR:
terms of such individual 3. vital signs give
22
damage; sudden situation 3. monitor vital signs an overview of extent
or slow onset of (sleeping, of pain
any intensity deep
from mild to breathing, 4. provide comfort 4. to promote non
 severe with an texting, back measures (touch, pharmacologic pain
anticipated or massage) repositioning), quiet management
predictable end environment and
and a duration of calm activites (deep
less than 6 breathing,
months meditating, sleeping,
back massage as
REFERENCE: tolerated)
Nurse’s Pocket
Guide (11th
edition)
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE
5. encourage use of 5. to divert attention
relaxation and reduce tension
techniques and
diversional activities
(texting, socializing
with others)
6. to prevent fatigue
6. encourage adequate
rest periods

Collaborative: 7. These medications

7. Administer block pain impulses
medications as by inhibiting
needed; prostaglandin
a. Analgesics synthesis in the CNS.

8. To identify readily and

8. Monitor for signs and manage effectively
symptoms of side those side effects that
effects. is detrimental to the
patient’s health.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE

Subjective data: Activity At the end of 8 1. Monitored vital signs 1. To provide baseline
“Madali akong intolerance hour, the patient every 2 hours. data; to evaluate the
mapagod kahit na r/t imbalance will be able to degree of condition and
mag – iba lang ako between participate willingly the effectiveness of the
ng posisyon”, as oxygen in necessary intervention
verbalized by the demand and activities and
patient. supply report measurable 2. Encouraged 2. To determine the
increase in activity expression of feelings necessary intervention
Objective Data: tolerance. contributing to the to be made for the
Weak in condition. client’s condition
appearance
PR: 102 3. Determined the 3. To determine the
dyspnea patient’s ability to assistance needed by
participate in the patient
activities in level of
mobility.

4. Planned care with rest 4. To reduce fatigue and

periods between to have enough rest
activities periods.

5. Instructed method to
conserve energy such 5. To restore energy
 as sitting instead of needed to perform ADL’s
standing during
activities.

6. Encouraged routines
like back rubbing to 6. To increase energy to
promote restful sleep. do ADL’s

7. Promoted overall
health measures 7. To promote wellness
(nutrition, vitamin
supplementation, &
adequate fluid intake.

8. Promoted safety
measures like lifting 8. To prevent injury &
the side rails of the fall
bed.

9. Involved client and SO

in planning of 9. involvement of client
activities as much as and SO during the plan
possible. of care helps to attain
goals