Student Nurses’ Community

NURSING CARE PLAN – Congenital Heart Failure

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Decreased Heart failure, After 8 hours of INDEPENDENT: After 8 hours of
cardiac output also called nursing • Auscultate apical pulse; • Tachycardia is nursing
“Putlang putla related to congestive intervention the assess heart rate, and usually present intervention the
ang anak ko, altered heart failure, patient will rhythm. even at rest to patient was able
nahihirapan sya myocardial occurs when display vital compensate for to display
huminga” (My contractility cardiac output is signs within decreased vital signs within
baby looks very pale /inotropic inadequate to acceptable ventricular acceptable
and she finds it changes. meet the limits, limits,
contractility.
difficult to breath)
metabolic dysrhythmias • Inspect skin for pallor, • Pallor is an dysrhythmias
as verbalize by demands of the controlled and controlled and
cyanosis. indicative of
the mother. body. The heart no symptoms of no symptoms of
diminished
rate increases failure. peripheral perfusion failure.
as a secondary to
OBJECTIVE: compensatory inadequate cardiac
mechanism to output,
• Cool, ashen increase cardiac vasoconstriction,
skin. output, and and anemia.
• Orthopnea vasoconstriction Cyanosis may
• Crackles occurs to try to develop in
maintain blood refractory heart
• V/S taken as pressure. failure. Dependent
follows Eventually, the areas are often blue
chronic increase or mottled as
T: 36.2 ˚C in preload and venous congestion
P: 130 afterload increases.
R: 45 contribute to • Monitor urine output, • Urine output is
chamber dilation noting decreasing usually decreased
and output and dark or during the day
hyperthrophy, concentrated urine. because of fluid
worsening heart shifts into tissues
failure. but may be
Underlying increased at night
causes of heart because fluid
failure include returns to
congenital heart circulation when
disease, patient is
rheumatic heart recumbent.
Student Nurses’ Community

disease, • Note changes in • May indicate

endocarditis, sensorium. inadequate cerebral
myocarditis, and perfusion
noncardiovascul secondary to
ar causes such decreased cardiac
as, chronic output.
pulmonary • Provide quiet • Psychological rest
disease, various environment. help reduce
metabolic emotional stress,
diseases, and which can produce
anemia. vasoconstriction,
Complications elevating BP and
of heart failure increasing heart
include rate or work.
pneumonia,
pulmonary
edema, DEPENDENT:
pulmonary • Administer • Increases available
emboli, supplemental oxygen oxygen for
refractory heart as indicated. myocardial uptake
failure, and to combat effects of
myocardial hypoxia or
failure. ischemia.
• Administer diuretics as • Diuretics, in
prescribed. conjunction with
restriction of dietary
sodium and fluids,
often lead to clinical
improvement in
patients with heart
failure.