NURSING CARE PLAN

Name of patient:
Age:
Diagnosis:
Attending Physician:
CUES & EVIDENCES

NURSING
DIAGNOSIS

SCIENTIFIC
BASIS

Goals &
Objectives

Independent:

SUBJECTIVE:
Below Normal man
akung Heart beats. as
verbalized by the
patient

Objectives:
The patient
manifested the
following:

with pale
conjunctiva, nail
beds and buccal
mucosa

irregular
rhythm of pulse

bradycardic

pulse rate of 34
beats/min

generalized
weakness

Vital signs taken as

follows:
BP: 140/100mmHg
T: 37.1C

IMPLEMENTATION

Decreased
cardiac output
related to
altered heart
rate and rhythm
AEB (Atrial
ectopic beats)
bradycardia

The heat fails to

pump
enough
blood to meet the
metabolic needs of
the
body.
The
blood flow that
supplies the heart
is also decreased
thus decrease in
cardiac
output
occurs, blood then
is insufficient and
making it difficult
to circulate the
blood to all parts
of the body thus
may cause altered
heart
rate
and
rhythm, weakness
and paleness

After 8 hours of
nursing
interventions,
the patient will
participate in
activities that
reduce the
workload of the
heart.
Outcome
Criteria:
After 8 hours of
nursing
intervention
patient will be
able to display
hemodynamic
stability

1.

Assess for abnormal

RATIONALE

1.

heart and lung sounds.

2.

Monitor blood pressure

and pulse.

3.

Assess mental status

2.

and level of
consciousness.
4.

Assess patients skin

temperature and

3.

peripheral pulses.
5.

Monitor results of
laboratory and
diagnostic tests.

6.

4.

Monitor oxygen
saturation and ABGs.

7.

Give oxygen as
indicated by patient
symptoms, oxygen
saturation and ABGs.

8.

5.

Implement strategies
to treat fluid and

6.

electrolyte imbalances.
9.

Administer cardiac
glycoside agents, as
ordered, for signs of left

7.

Allows detection of left-sided

heart failure that may occur with
chronic renal failure patients due
to fluid volume excess as the
diseased kidneys are unable to
excrete water.
Patients with renal failure are
most often hypertensive, which is
attributable to excess fluid and
the initiation of the renninangiotensin mechanism.
The accumulation of waste
products in the bloodstream
impairs oxygen transport and
intake by cerebral tissues, which
may manifest itself as confusion,
lethargy, and altered
consciousness.
Decreased perfusion and
oxygenation of tissues secondary
to anemia and pump
ineffectiveness may lead to
decreased in temperature and
peripheral pulses that are
diminished and difficult to
palpate.
Results of the test provide
clues to the status of the disease
and response to treatments.
Provides information
regarding the hearts ability to
perfuse distal tissues with
oxygenated blood
Makes more oxygen
available for gas exchange,

EVALUATION

After 8 hours of
nursing
interventions, the
patient was able to
participate in
activities that reduce
the workload of the
heart
Goal is Met
After 8 hours of
nursing
interventions, the
patient was able to
display
hemodynamic
stability.
Goal is Met

PR: 34bpm
RR: 11cpm

sided failure, and

monitor for toxicity.
10. Encourage periods of

8.

rest and assist with all

activities.

9.

11. Assist the patient in

assuming a high
Fowlers position.
12. Teach patient the
pathophysiology of
disease, medications
13. Reposition patient
every 2 hours

10.
11.
12.

14. Instruct patient to get

adequate bed rest and
sleep
15. Instruct the SO not to
leave the client

13.

assisting to alleviate signs of

hypoxia and subsequent activity
intolerance.
Decreases the risk for
development of cardiac output
due to imbalances.
Digitalis has a positive
isotropic effect on the
myocardium that strengthens
contractility, thus improving
cardiac output.
Reduces cardiac workload
and minimizes myocardial
oxygen consumption.
Allows for better chest
expansion, thereby improving
pulmonary capacity.
Provides the patient with
needed information for
management of disease and for
compliance.
To prevent occurrence of bed
sores

14.

To promote relaxation to the

body

15.

To ensure safety and reduce

risk for falls that may lead to
injury

16.

To treat underlying
problem

unattended

Collaborative:
16. Administer drugs as
ordered.

NURSING CARE PLAN

Name of patient:
Age:
Diagnosis:
Attending Physician:
CUES & EVIDENCES

NURSING
DIAGNOSIS

SCIENTIFIC
BASIS

Goals &
Objectives

IMPLEMENTATION

RATIONALE

EVALUATION

Independent:

Subjective:
Luya pajud akong
panglawas kapoy e lihok
as verbalized by the
patient

Objectives:
The patient
manifested the
following:

generalized
weakness

Slow
Movements noted

limited range
of motion as
observed
abnormal pulse
rate and rhythm
(+) DOB

Vital signs taken as

follows:
BP: 140/100mmHg
T: 37.1C
PR: 34bpm
RR: 11cpm)

Activity
intolerance
related to
imbalance
Oxygen supply
and generalized
weakness

As heart failure
becomes more
severe, the heart
is unable to pump
the amount of
blood required to
meet all of the
bodys needs. To
compensate, blood
is diverted away
from less-crucial
areas, including
the arms and legs,
to supply the heart
and brain. As a
result, people with
heart failure often
feel weak
(especially in their
arms and legs),
tired and have
difficulty
performing
ordinary activities
such as walking,
climbing stairs or
carrying groceries

After 8 hours
of nursing
interventions,
the patient
will use
identified
techniques to
improve
activity
intolerance
Outcome
Criteria:
After 8 hours
of nursing
intervention
patient will
report
measurable
increase in
activity
tolerance

1.
2.

Establish Rapport

1.

Monitor and record

Vital Signs

3.

Assess patients
general condition

4.

Adjust clients daily

2.
3.

activities and reduce

intensity of level.
Discontinue activities that
cause undesired

4.

psychological changes
5.

To gain clients
participation and
cooperation in the nurse
patient interaction
To obtain baseline data
To note for any
abnormalities and
deformities present within
the body
To prevent strain and
overexertion

Instruct client in

energy
6.

Encourage patient to
have adequate bed rest

5.
6.

To conserve energy and

promote safety
to relax the body

Provide the patient

with a calm and quiet

7.

Assist the client in

to prevent risk for falls

that could lead to injury

9.

fatigue affects both the

clients actual and perceived
ability to participate in
activities

10.

to determine current
status and needs associated
with participation in needed
or desired activities

11.

to sustain motivation of
client

ambulation
9.

Note presence of
factors that could
contribute to fatigue

10.

Ascertain clients
ability to stand and move
about and degree of
assistance needed or use
of equipment

11.

to provide relaxation

8.

environment
8.

Give client
information that provides

The patient was able

to report an increase
in activity tolerance.
Goal is Met

and sleep
7.

- gradual increase in
activity level as
tolerated
- rest in between
activities
Goal is met

unfamiliar activities and in

alternate ways of conserve

After 8 hours of
nursing intervention
the client was able to
use identified
techniques to
improve activity
intolerance

12.

to enhance sense of well

being

evidence of daily or
weekly progress
12.

Encourage the client

to maintain a positive

13.

to promote easy
breathing

14.

to maintain an open
airway

attitude
13.

Assist the client in a

semi-fowlers position

14.

Elevate the head of

the bed

15.

Assist the client in

learning and

15.

to prevent injuries

16.

to avoid risk for falls

demonstrating appropriate
safety measures
16.

17.

to help minimize
frustration and rechannel
energy

18.

to indicate need to alter

activity level

Instruct the SO not to

leave the client
unattended

17.

Provide client with a

positive atmosphere

18.

Instruct the SO to
monitor response of
patient to an activity and
recognize the signs and
symptoms

Collaborative:
19. Administer drugs as
ordered.

19. To treat underlying problem

NURSING CARE PLAN

Name of patient:
Age:
Diagnosis:
Attending Physician:
CUES & EVIDENCES

NURSING
DIAGNOSIS

SUBJECTIVE:
Lisod man e ginhawa,
Nars as verbalized by
the patient

Objective:
Patient manifested:

with productive
cough yellowish in
color

presence of rales
upon auscultation

(+) Difficulty Of
Breathing

with pale
conjunctiva, nail
beds and buccal
mucosa

Ineffective
airway
clearance
related to
Retained
secretions AEB
presence of
rales on both
lung fields.

SCIENTIFIC
BASIS
Mucus is produced
at all times by the
membranes lining
the air passages.
When
the
membranes
are
irritated
or
inflamed,
excess
mucus is produced
and it will retain in
tracheobronchial
tree.
The
inflammation and
increased
in
secretions
block
the
airways
making it difficult
for the person to
maintain a patent
airway. In order to
expel
excessive
secretions, cough
reflex
will
be
stimulated.
An
increased in RR

Goals &
Objectives

IMPLEMENTATION

RATIONALE

EVALUATION

Independent:
1.

Monitor and
record vital signs.

After 8 hours of
nursing
2.
Assess patients
interventions,
condition.
the patient will
be able to
3.
Monitor
establish and
respirations and
maintain airway
breath sounds,
patency AEB
noting rate and
absence of signs
sounds.
of respiratory
distress.
4.
Position head
Outcome
Criteria:
After 8 hours of
nursing
intervention
patient will be
able to
demonstrate
improve airway
clearance AEB
reduction of
congestion with

properly

1.

To obtain baseline data

2.

To know the patients

general condition

3.

To determine respiratory
distress and accumulation of
secretions.

4.

To open or maintain open

airway.

5.

To prevent vomiting with

aspiration into lungs.

5.

Position
appropriately and
discourage use of oilbased products
6.
To ascertain status and
around nose.
note progress.

6.

Auscultate
breath sounds and
assess air
movement.

7.

To maximize effort

8.

To promote maximal

After 8 hours of
nursing
interventions, the
patient was able to
able to establish and
maintain airway
patency AEB absence
of signs of
respiratory distress.
Goal is Met
After 8 hours of
nursing
interventions, the
patient was able to
demonstrate improve
airway clearance AEB
reduction of
congestion with
breath sounds clear
and improved RR..

Vital signs taken as

follows:
BP: 140/100mmHg
T: 37.1C
PR: 34bpm
RR: 11cpm

will
also
be
expected
as
a
compensatory
mechanism of the
body
due
to
obstructed
airways.

breath sounds
clear and
improved RR.

7.

Encourage deep
breathing and
coughing exercises

8.

Elevate head of
bed and encourage
frequent position
changes.

9.

Keep back dry

and loosen clothing

10.

Observed for
signs and symptoms
of infection.

11.

Instruct patient
have adequate rest
periods and limit
activities to level of
activity intolerance.

12.

Suction
secretions PRN

Collaborative:
13.

Give
expectorants and
bronchodilators as
ordered.

14.

Administer
oxygen therapy and
other medications as
ordered.

inspiration, enhance
expectoration of secretions in
order to improve ventilation
9.

To promote comfort and

adequate ventilation

10.

To identify infectious
process and promote timely
intervention.

11.

Rest will prevent fatigue

and decrease oxygen
demands for metabolic
demands

12.

To clear airway when

secretions are blocking the
airway

13.

To further mobilize
secretions

14.

Indicated to increase
oxygen saturation.

Goal is Met

NURSING CARE PLAN

Name of patient:
Age:
Diagnosis:

Attending Physician:
CUES & EVIDENCES

SUBJECTIVE:
Murag naay mo bara
sa akong gininhawa.an
as verbalized by the
patient

Objectives:
The patient manifested
the following:

productive cough
yellowish in color

presence of rales
upon auscultation

(+) DOB

Tachypnic AEB
RR= 27bpm

with pale
conjunctiva, nail
beds and buccal
mucosa

fatigue

Patient may manifest:

Metabolic
acidosis

Circum-oral
cyanosis

NURSING
DIAGNOSIS

SCIENTIFIC
BASIS

Goals &
Objectives

IMPLEMENTATION

RATIONALE

EVALUATION

Independent:
Impaired gas
exchange
related to
inflammation of
airways and
accumulation of
fluid in the
alveoli

The exchange in
oxygenation and
carbon
dioxide
gases is impeded
due
to
the
obstruction
caused by the
accumulation of
bronchial
secretions in the
alveoli. Oxygen
cannot
diffuse
easily.

After 8 hours of
nursing
interventions,
the patient be
able to
demonstrate
improvement in
gas exchange
AEB a decrease
in respiratory
rate to normal,
and absence of
pallor
Outcome
Criteria:
After 8 hours of
nursing
intervention
patient will be
able to
demonstrate
improved
ventilation and
adequate
oxygenation of
tissues AEB
absence of
symptoms of
respiratory
distress

1.

Monitor and
record vital signs

2.

Observe color of
skin, mucous
membranes and nail
beds, noting
presence of
peripheral cyanosis.

3.

Elevate head of
bed and encourage
frequent position
changes.

4.

Keep back dry.

5.

Promote
adequate rest
periods

6.

Change position
q 2 hrs.

7.

1.

To obtain baseline data

2.

Cyanosis of nail beds may

represent vasoconstriction or
the bodys response to fever/
chills

3.

To promote maximal
inspiration, enhance
expectoration of secretions in
order to improve ventilation

4.

To avoid coughing

5.

Rest will prevent fatigue

and decrease oxygen
demands for metabolic
demands

6.

To promote drainage of
secretions

Keep
7.
To reduce irritant effects
environment allergen
on airways
free
8.
To clear airway when
8.
Suction
secretions are blocking the
secretions PRN
airway.
Collaborative:
9.
O2 therapy is indicated to
9.
Administer
increase oxygen saturation
oxygen therapy as
ordered.

After 8 hours of nursing

interventions, the
patient was able to
demonstrate
improvement in gas
exchange AEB a
decrease in respiratory
rate to normal, and
absence of pallor
Goal is Met
After 8 hours of nursing
interventions, the
patient was able to
demonstrate improved
ventilation and
adequate oxygenation
of tissues AEB absence
of symptoms of
respiratory distress
Goal is Met