ASSESSMENT

Pale

conjunctiva, nail
beds, and
buccal mucosa
irregular
rhythm of pulse
bradycardia
generalized
weakness

DIAGNOSIS
Decreased
cardiac output
r/t [altered
heart rate and
rhythm] AEB
[bradycardia]

PLANNING

Short
Term: After 3-4
hours of nursing
interventions,
the patient will
participate in
activities that
reduce the
workload of the
heart.
Long
Term: After 2-3
days of nursing
interventions,
the patient will
be able to
display
hemodynamic
stability.

INTERVENTION
* Assess for

abnormal heart
and lung sounds
* Monitor blood
pressure and pulse
* Assess mental
status and LOC
* Implement
strategies to treat
fluid and

electrolyte
imbalances
* Reposition pt
every 2 hours
* Instruct pt to get
adequate bed rest

EVALUATION
After nursing
interventions,
the patient shall
have
participated
in
activities
that
reduce
the
workload of the
heart.
After
2-3
days of nursing
interventions,
the patient shall
have been able
to
display
hemodynamic
stability.

CONGESTIVE HEART FAILURE