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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.


Administer supplemental Increases available

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


Monitor laboratory results For early detection on

abnormal changes in body