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Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: After 8 hours of  Record intake  Reduced cardiac At the end of 8-


Decreased Cardiac nursing and output. If output results in hour Nursing
Output related to intervention the patient is reduced perfusion Interventions, th
Objective: Alteration in heart patient will be able acutely ill, of the kidneys, goal was partiall
 Generalized rate, rhythm, and to: measure hourly with a resulting met as evidenced
paleness noted conduction  Demonstrate urine output and decrease in urine by:
 Irregular rhythm of hemodynamic note decreases output.
pulse noted stability (Blood in output.  PR = 92bpm
PR – 123bmp pressure and  Cardiac
BP- 150/100 cardiac output) monitoring
by 31%-80% as revealed sligh
revealed in the disturbance
cardiac monitor  For patients
 Manifest with increased  Closely monitor
absence of preload, limit fluid intake
angina fluids and including IV lines.
sodium as Maintain fluid
ordered. restriction if
ordered.

 Auscultate heart
sounds; note
rate, rhythm,  The new onset of
presence of S3, a gallop rhythm,
S4, and lung tachycardia, and
sounds. fine crackles in
lung bases can
indicate onset of
heart failure. If
patient develops
pulmonary
edema, there will
be coarse crackles
on inspiration an
d severe dyspnea.

 Closely monitor  As these


for symptoms of symptoms of
heart failure and heart failure
decreased progress, cardiac
cardiac output, output declines.
including
diminished
quality of
peripheral
pulses, cold and
clammy skin and
extremities,
increased
respiratory rate,
presence of
paroxysmal
nocturnal
dyspnea or
orthopnea,
increased heart
rate, neck vein
distention,
decreased level
of
consciousness,
and presence of
edema.

 Note chest pain.


Identify location,
radiation,
severity, quality,
duration,
associated
manifestations
such as nausea,
and
precipitating
and relieving
factors.  Chest
pain/discomfort
is generally
 Kept client on suggestive of an
bed in Semi- inadequate blood
fowler’s and supply to the
administered heart, which can
high flow O2 via compromise
nasal cannula. cardiac output.
Patients with
heart failure can
continue to have
chest pain
with angina or
can reinfarct.
 To Facilitate
oxygenation