Name of Patient: Cardio Dalisay Room #: 199

Age:56 Attending Physician: Dr.Jimjim de la Cruz

Sex: M Diagnosis: Congestive Heart Failure

Nursing Nursing
Assessment Rationale Planning Rationale Evaluation
Diagnosis Interventions
Subjective: Short term Goal: Independent: Short term:
“My feet are Failure of the left After 8 hours of 1. Auscultate breath ➢ May indicate
swelling and I can’t Fluid Volume and/or rightnursing sounds for presence of pulmonary edema After 8 hours of nursing
move at all” Excess related chambers of the interventions the crackles secondary to cardiac interventions the patient
to heart results in patient will have decompensation was not able to have
Objective: inability to provide improved fluid (Source: 3rd edition improved fluid volume
• Bipedal pitting
compromised sufficient output volume condition, Nursing Care Plans, condition but has better
edema (+3) regulatory to meet tissue better lung sounds Doenges, lung sounds and vital signs
• Crackles sound mechanism needs and causes and vital signs Moorhouse, Geissler within acceptable range
noted upon Pulmonary within acceptable p.91)
auscultation
(heart failure) congestion, range
• T: 35.6 °C leading to 2.compare current ➢ Sudden changes in Long Term:
• PR: 118bpm pulmonary weight with admission weight reflect
(Source: 12th interstitial edema Long Term Goal: and/or previously alterations in fluid After 1-2 days of nursing
• RR: 25cpm
edition Nurse’s and edema of the After 1-2 days of stated weight balance intervention, the client
• BP: 80/50 Pocket Guide, lower extremities. nursing (Source: 3rd edition was not able to have
mmHg Doenges,
• O2 sat: 94-95% intervention, the Nursing Care Plans, stabilized fluid volume but
Moorhouse, Murr, (Source: 11 th client will have Doenges, has clear lung sounds as
• Decreased urine p.376)
output – 500 ml edition Medical- stabilized fluid Moorhouse, Geissler manifested by absence of
per day Surgical Nursing, volume, has clear p.92) crackles, vital signs within
• X-ray Findings: Smeltzer, Bare, lung sounds as acceptable range, and
Normal heart Hinkle et al. p.950) manifested by decreased peripheral
size. Interstitial absence of crackles; edema
and perihilar vital signs within 3. place in semi- ➢ May promote
butterfly acceptable range Fowler’s position as recumbency-induced
pattern alveolar and decreased appropriate diuresis and facilitate
pulmonary peripheral edema respiratory effort
edema. when movement of Goal partially met
the diaphragm is
limited/ breathing is
impaired
(Source: 14th edition
Nurse’s Pocket Guide,
Doenges,
Moorhouse, Murr,
p.343)

4. elevate edematous ➢ To reduce tissue

extremities, change pressure and risk for
position frequently skin breakdown.
(Source: 12th edition
Nurse’s Pocket Guide,
Doenges,
Moorhouse, Murr,
p.378)

5. Keep feet dry and ➢ Prolonged immobility

provide padding as and bed rest are
indicated cumulative stressors
which affects the skin
integrity
(Source: 3rd edition
Nursing Care Plans,
Doenges,
Moorhouse, Geissler
 p.56)

6. Instruct patient ➢ Information and

regarding fluid knowledge about
restriction as condition are vital to
appropriate patients who will be
comanaging fluids
(Source: 11th edition
Medical- Surgical
Nursing, Smeltzer,
Bare, Hinkle et al.
p.951)

7. Provide oral care ➢ To reduce discomfort

(use of lip balm) of fluid restrictions.
(Source: 12th edition
Nurse’s Pocket Guide,
Doenges,
Moorhouse, Murr,
p.379)

8. Advised NPO ➢ Restriction of sodium

temporarily, low salt aids in decreasing
with SAP as fluid retention
appropriate (Source: 12th edition
Nurse’s Pocket Guide,
Doenges,
Moorhouse, Murr,
p.376)
Dependent: ➢ CHF, including that due
1. Give Digoxin 0.25 to venous congestion,
mcg 1 tab OD as edema
ordered (Source: 2008 edition
Nurses Drug
Handbook, Sparatto,
Woods p. 456)

2. Insert FBC (Fr- 16) ➢ To monitor urine

and attach to urobag output
as ordered (Source: 14th edition
Nurse’s Pocket Guide,
Doenges,
Moorhouse, Murr,
p.349)
Collaborative:
1. Monitor chest ➢ Reveals changes
xray indicative of increase/
resolution of
pulmonary congestion
(Source: 3rd edition
Nursing Care Plans,
Doenges, Moorhouse,
Geissler p.57)

2. Consult with ➢ May be necessary to

dietitian provide diet acceptable
to patient that meet
caloric needs with
sodium restriction
(ibid.)