Sei sulla pagina 1di 3

ASSESSMENT NSG. DIAGNOSIS PLANNING NSG.

INTERVENTION RATIONALE EVALUATION


SUBJECTIVE: Independent STG:
Ineffective breathing STG: After 1hr of nursing Note heart sounds. S1 and S2 may be weak After 1 hr. of nursing
 “Is very anxious pattern related to fatigue intervention the patient because of diminished intervention the patient
and ask, “Am I and decreased lung will be able demonstrate 3 pumping action. Gallop was able to demonstrate 3
going to die?” expansion and pulmonary out of 5 procedures to rythms are common(S3 out 5 ways to improve
 Denies pain but congestion secondary to improve breathing pattern and S4), produced as breathing pattern.
says that he feels CHF. blood flows into
like he cannot get LTG: After 8hrs of nursing noncompliant chambers. GOAL MET
enough air intervention the Patient’s
 Says that his heart respiratory pattern will Palpate peripheral pulses ↓CO may be reflected in LTG:
feels like it is decrease from 34 to 28 diminished radial, After 8 hrs. of nursing
“running away” cpm without exertion. popliteal, dorsalis pedis, intervention the patient’s
 After being and post tibial pulses respiratory pattern was
weighed, he decreased from 34-28
reports, “that is Monitor BP In advanced HF, the body cpm without exertion.
more than I may no longer be able to
usually weigh” compensate, and GOAL MET
 Reports that he is profound hypotension may
so exhausted he occur.
can’t eat or drink
by himself Inspect for pallor or Pallor is indicative of
Objective Data cyanosis diminished peripheral
 Height: 175 cm perfusion secondary to
 Weight: 95.5kg inadequate CO,
Temp: 37.6 vasoconstriction, and
HR: 34 anemia. Cyanosis may
118bpm develop in refractory HF.
BP: 90/60 Dependent area are often
blue or mottled as venous
 Distant S1, S2,
congestion increases.
S3, S4 present,
Monitor UO Kidneys respond to
PMI at 6th ICS and
reduced CO by retaining
faint water and sodium
 (+) atrial fibrillation Note changes in May indicate inadequate
sensorium, lethargy, cerebral perfuaion
with ventricular
confusion, disorientation, secondary to decreased
rate of 132pbm anxiety, and depression CO.
 (+)crackles, Monitor oxygen saturation Provides information
↓breath sounds and ABGs. regarding the heart’s
ability to perfuse distal
RLL, +(frothy tubules with oxygenated
blood-tinged blood.
sputum) Encourage patient of rest Reduces cardiac workload
 SpO2- 82% on and assist with all and minimizes myocardial
activities oxygen consumption
room air
 (+) bowel sounds Assist the patient in Allows for better chest
assuming a high fowler’s expansion, thereby
 Hepatomegaly position improving pulmonary
(4cm below costal capacity.

margin) Assist patient to use Identifies increased work


 Bilateral JVD relaxation techniques of breathing

 1+ peripheral Weigh patient daily and Body weight is a sensitive


compare to previous indicator of fluid balance
pulses and (+)
weights and an increase indicates
peripheral edema fluid volume excess.

Dependent:

Administer supplemental Increases available


oxygen as indicated oxygen for myocardial
uptake to combat effects
of hypoxia
Administer medications as To improve patient
indicated. condition

Interdependent:

Monitor laboratory results For early detection on


abnormal changes in body
function.