NURSING CARE PLAN

Assessment Diagnosis Scientific GOAL Intervention Rationale Evaluation

Explanation

Decreased Occlusion in After 30-mins of  Monitor Vital  Most patients After 30-mins of
SUBJECTIVE: Cardiac the artery nursing intervention signs specially have nursing intervention
Output the patient will be blood pressure compensatory the patient blood
N/A tachycardia in pressure is decreased
related to able to:
response to
altered Decreased from 180/100mmHg
 Demonstrate reduced
blood flow blood supply to 140/90mmHg. And
hemodynam cardiac output.
OBJECTIVE : a Pulse pressure of
to the ic stability  Monitor  To
>Abnormal myocardial (blood electrocardiogra differenciate
Heart Sound tissue . Decreased pressure m (ECG) the Cardiac
S3 and S4. venous and pulse dysrhythmias
>Poor return rate within and can further
Capillary refill normal compromise
>Chest pain parameters cardiac output.
>Dyspnea Decreased for patient)  Auscultate heart  The new onset
>Dysrhythmias amount of sounds; note of a gallop
>Cold Clammy blood rate, rhythm, rhythm,
Skin expelled by  Manifest presence of S3, tachycardia,
BP: ventricles absence of S4, and lung and fine
150/100mmHg angina sounds. crackles in
lung bases can
RR: 25cpm indicate onset
Decreased of heart failure.
PR: cardiac If patient
output develops
pulmonary
edema, there
will be coarse
 crackles on
inspiration and
severe
dyspnea.
 Assess for  Decreased card
Peripheral pulses iac output
including may indicate d
capillary refill ecreased radial
artery,
popliteal,
dorsalis, pedis
and posttibial

 Assess for skin  Pale indicating

color. reduced
peripheral
perfusion seco
ndary to
inadequate car
diac output
 Assess oxygen  An alteration
saturation with in oxygen
pulse oximetry saturation is
one of the
earliest signs
of reduced
cardiac output.

 Kept client on  Upright

bed in Semi- position is
Fowler’s recommended
and to reduce
administered preload and
 high flow O2 ventricular
Via nasal filling when
Cannula fluid overload
is the cause.
 Closely monitor Increase
for symptoms dosage
of heart failure myocardial
oxygen to the
need to counter
the effects of
hypoxia /
ischemia

 As these
symptoms
of heart
failureprogress
, cardiac output
declines.