‫بسم هللا الرحمن الرحيم‬

Nursing care plan

Prioritized nursing diagnoses:

Nursing Diagnosis :
1-Risk for decreased cardiac output may be related to altered myocardial
contractility, secondary to temporary factors, such as ventricular wall
surgery.

The goal:
Long Term &Short Term: After 8 hours of nursing interventions, the
patient will demonstrate display homodynamic stability, such as stable
blood pressure and cardiac output.
Nursing intervention Rational Evaluation
1-Monitor and
document heart Tachycardia is the most After 8 hours of nursing
rate and blood common response to interventions, the patient
pressure; especially discomfort, inadequate was able to demonstrate
noting hypertension blood or fluid replacement, display homodynamic
stability, such as stable
and the stress of surgery.
blood pressure and
2-Observe for
cardiac output.
bleeding from Helps identify bleeding
incisions and chest complications that can
tube reduce circulating volume,
organ perfusion, and cardiac
function.

3-Observe for May indicate decreases

changes in usual cerebral blood flow or
mental status, oxygenation as a result of
orientation, ad body diminished cardiac output.
movement or
reflexes.
Warm. Pink and strong,
equal pulses are general
4-Record skin indicators of adequate
temperature and cardiac output.
color and quantity
and equality of
peripheral pulses.
5-Measure and Useful in determining fluid
document intake needs or identifying fluid
and output and excesses, which can
calculate fluid compromise cardiac output
imbalance. and oxygen consumption.

May be indicative of acute or

chronic heart failure..
6-Inspect for jugular
vein distention. Most frequently done to
follow the progress in
normalization of electrical
7-Review serial conduction patterns and
ECGs. ventricular function after
surgery or to identify
complications.

Promotes maximal
oxygenation to reduce
8-Administer cardiac workload and aid in
supplemental resolving myocardial
oxygen as indicated.
irritability and dysrhythmias.
Nursing Diagnosis:
2-Impaired gas exchange related to trauma of extensive chest surgery

Goal:-
S.T.G:- The pt will have improved gas exchange within 2h.
L.T.G:-Increase respiration rate to the pt without any problem and improve gas exchange
during hospitalization (2-3day).

Nursing intervention Rational Evaluation

1. Allow the pt to assume 1.Assuming comfortable position All nursing action are
comfortable position. helps making breathing. met , the pt locks
comfortable& he
2. Provide cool moist 2.Cool mist humidifies the airway cough more , he feel
environment like face helps thin secretion. the respiratory tract
masked. clean from mucus as
he said ,
3.O2 helps decrease restlessness
3. Administer O2 by face associated with respiratory
mask as Dr Order. distress.

4. Encourage pt to cough 4.Coughing aid in the removed of

and deep breathe every secretion. Aids in keeping airway
2hrs. patent, expansion .preventing
atelectasis , and facilitating lung.

5.Suction may be necessary to

5. Suction the pt as needed
maintain airway potency.

6. Perform chest
6.Chest physiotherapy helps
physiotherapy every 4hrs
loosen exudates and secretion for
as order.
easy removal through coughing
and suctioning.
7. Encourage oral fluid
7.Al thought fluids generally
intake.
liquefy secretion.

8.To conserve energy to fight

8. Provide frequent rest
period. infection.
Nursing Diagnosis:
3-Ineffective renal tissue perfusion related to decrease cardiac output.

Short term goal: maintain of adequate renal perfusion.

Long term goal: prevent renal failure.
Nursing intervention Rational Evaluation

1- Measure urine less than 25ml/h The goal is met partially

output every half of indicate decreased there is moderate urine
hour to 4 hour in renal function output
critical care

indicate kidneys ability

2- Measure urine to concentrate urine in
specific gravity
renal tubule.

3- Monitor and report indicate kidney ability

the lab result (BUN, to excrete waste
serum creatinine, urine products.
and serum electrolyte)

4- Prepare to
To increase cardiac
administer diuretic as
output and renal flow
prescribed
promote renal function
Nursing Diagnosis :
4-Risk for infection r /to immunosuppression; invasive procedures &tissue
destruction

Long Term:
Client will remain free from symptoms of infection as measured by WBC within
normal limits to be evaluated before discharge.

Short Term:
Client will demonstrate appropriate care of infection-prone site to be evaluated
by end of shift .

Nursing intervention Rational Evaluation

The white blood cell
1-Note and report count and the
laboratory values (e.g., automated absolute
white blood cell count and neutrophil count are
differential, serum better diagnostic tests
protein, serum albumin, for adults and most
and cultures). children

2-Observe and report because careful

signs of infection such as
warmness, redness,
discharge, or increased
body temperature .
surveillance of infection
should be monitored and
increased body
temperature of
unknown origin is the
most common sign of
infection.

3- Teach the client to also

recognize these signs as
symptoms (redness,
warmness, swelling,
discharge, and increased
body temperature)
because once
discharged, the client
needs to know when to
report back to the
doctor for possible
infection
Nursing Diagnosis :
5-Anxiety R\T his disease and his condition in the hospital (his facial
expression that guide to anxiety).

Goal:-
Long Term( L.T.G) :
1. Help pt to decrease his anxiety and decrease anger within 2hrs.
2. Help pt to express about his condition within 2hrs.
Short Term:
The pt will be able cope with anxiety and with his disease during
hospitalization.
Nursing intervention Rational Evaluation
1. Assess the level of 1. To determine the All nursing action are met
anxiety. cause of anxiety. and the pt become talk
about his condition and
2. using flexible 2. to reduced anxiety and anger is
decrease gradually
visiting hours for anxiety for pt.
his family and family

3. Teach relaxation 3. To feel comfort

exercise such as deep and good
breathing. to condition.
encourage pt to do
bathing.

4. to encourage pt to 4. to expand lungs,

perform semi and reduce
sitting position . dyspnea.

5. Use physical touch. 5. To keep the pt

relaxes without
noise or fear.