NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

No subjective cues. Decreased Cardiac Output After 8 hours of INDEPENDENT Within the 8 hours of holistic
related to alteration in holistic nursing care,  Evaluate patient’s reports - To assess for signs of poor nursing care, the patient was
Objective Cues: heart rate as evidenced by the patient will be and/or evidence of extreme ventricular function and/or able to maintain BP within
Received patient on 43bpm secondary to ADHF. able to maintain fatigue and intolerance for impending cardiac failure. normal limits, regular cardiac
bed, awake, with Blood Pressure activity. rhythm and regular or within the
NGT attached for within normal limits, - Provides a baseline for range peripheral pulses, and
 Assess and monitor vital
feeding; with an ET
regular cardiac signs. comparison to follow trends maintain warm, and dry skin.
tube attached to a
mechanical ventilator rhythm and equal and evaluate response to
with a setting mode: peripheral pulses, interventions.
SIMV mode, F1O2: and maintain warm,  Assess urine output hourly - To allow for timely alterations
40%, TV:350mL, , dry skin. or periodically in therapeutic regimen.
PEEP 4.8; hooked at  Keep client on bed rest or - For comfort and to maximize
cardiac monitor with adequate rest periods. cardiac output.
a scope of sinus  Encourage relaxation - To reduce anxiety, muscle
bradycardia; with #7 tension.
technique.
PNSS 1L regulated @
 Encourage changing - To reduce risk of orthostatic
20cc/min with a side
positions slowly hypotension
drip of 90cc PNSS +
100mg Furosemide  Elevate the lower - This promotes venous return
regulated @ 30cc/hr; extremities
with D5W 46cc +  Monitor the rate of IV - To prevent bolus or overdose.
4mg Norepinephrine drugs closely, using infusion
regulated @ 9cc/hr pumps, as appropriate.
hooked at right  Provide a quiet - To promote adequate rest.
metatarsal vein
environment
infusing well; (+) - To reduce anxiety, muscle
cough; (+) crackles;  Encourage relaxation
techniques tension, and to conserve
with V/S: BP-90/80,
 Elevate legs when in sitting energy.
P-43, R-12, T-37oC,
O2-97%. position - This improves venous return
and systemic circulation, and
reduces the risk of
 Provide skin protective thrombophlebitis.
measures - To avoid the development of
pressure sores.
DEPENDENT
  Administer medications as
prescribed or ordered.
 Administer oxygen via mask
or ventilator as indicated.
 Administer/provide fluids
and electrolytes as
indicated.
 Restrict or administer fluids
as indicated
 Administer antipyretic or
cooling measures, as
indicated
COLLABORATIVE
 Assist with performing self-
care activities for patient.
 Assist in changing position
for the patient.
NOTE:
 Avoid the use of restraints
whenever possible if the
client is confused.
- To maximize cardiac output.
- To increases oxygen available
for cardiac function.
- To minimize hydration and
dysrhythmias.
- If cardiopulmonary congestion
is present.
- To maintain body temperature
in normal range.
- For patient’s comfort and to
maintain proper hygiene.
- To promote wellness and
reduce risk of orthostatic
hypotension.
- May increase agitation and
increases the cardiac
workload.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

No subjective cues. Ineffective airway clearance After 8 hours of INDEPENDENT Within the 8 hours of holistic
related to retained holistic nursing care,  Assess airway for patency. - Maintaining the airway nursing care, the patient was
Objective Cues: secretions as evidence by the patient will be patency is always the first able to maintain airway patency
Received patient on changes in respiratory rate able to maintain priority. and expectorate or clear
bed, awake, with and crackles secondary to airway patency and - To ascertain current status secretions
 Auscultate lung sounds for
NGT attached for
Pneumonia. expectorate or clear presence of adventitious and may indicate increase
feeding, with ET tube
attached to secretions breath sounds such as airway resistance.
mechanical ventilator crackles, wheezing. - To maintain and promote
with a setting of  Keep environment allergen wellness and patent airway.
SIMV mode,F1O2- free.
40%, TV.350mL ,  Increase fluid intake to at - Hydration can help prevent
PEEP 4.8; hooked at least 2,000 ml/day within the accumulation of secretion
cardiac monitor with cardiac tolerance. and improve secretion
a scope of sinus clearance.
bradycardia; with #7
 Elevate head of the bed - This facilitates movement of
PNSS 1L regulated @
and change position every secretions
20cc/min with a side
drip of 90cc PNSS + 2 hours. - Allows one to monitor
100mg Furosemide  Monitor vital signs esp. BP changes
regulated @ 30cc/hr; and HR - This facilitates dislodgment of
and D5W 46cc + 4mg  Perform chest and back secretions
Norepinephrine tapping - To remove/clear airway when
regulated @ 9cc/hr  Suction nose, mouth, and excessive secretions are
hooked at right blocking the airway.
trachea as necessary.
metatarsal vein - Indicative of respiratory
infusing well; Mucus
 Monitor respiration and distress and/or accumulation
secretion is yellowish
breath sounds, noting the of secretion.
in color, copious and
mucoid in rate and sounds - Reduces the risk of atelectasis,
characteristic, (+)  Mobilize the client as soon enhancing lung expansion and
cough; (+) crackles; as possible drainage of different lung
with V/S: BP-90/80, segment.
P-43, R-12, T-37oC,  Evaluate client’s cough/gag - To determine ability to protect
O2-97%. own airway.
reflex, amount and type of
secretions, and swallowing
ability
  Observe for sign and
symptoms of infection - To identify infectious process
and promote timely
 Provide opportunities for intervention.
rest; limit activities to level - This prevents or reduces the
of respiratory tolerance risk of fatigue.
DEPENDENT
 Administer medication as
prescribed. - To relax smooth respiratory
musculature and help in
COLLABORATIVE clearing airway.
 Assist in changing position
for the patient. - To promote wellness and
reduce risk of orthostatic
 Assist with procedures hypotension.
- To clear/maintain open
 Assist the client in learning airway.
airway clearance - To acquire and maintain
techniques, such as adequate airways and
postural drainage and improve respiratory functions
percussion and gas exchange.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

No subjective cues. Imbalanced nutrition: less After 8 hours of INDEPENDENT Within the 8 hours of holistic
than body requirements holistic nursing care,  Assess drug interactions, - They may be affecting the nursing care, the patient was
Objective Cues: related to inability to ingest the patient will be diseases effects. appetite, food intake or able to demonstrate progressive
Received patient on food as evidenced by BMI able to demonstrate absorption. weight gain and/or maintain
bed, awake, with of 17.2 progressive weight  Assess weight. - To evaluate degree of deficit. appropriate weight.
NGT attached for gain and/or maintain To establish baseline
feeding; with an ET
appropriate weight. parameters.
tube attached to a
mechanical ventilator  Auscultate bowel sounds.
with a setting mode:  Note age, body build, - To enhance monitoring of
SIMV mode, F1O2: strength, activity level, and intake.
40%, TV:350mL, , current condition.
PEEP 4.8; hooked at  Promote pleasant, relaxing
cardiac monitor with environment.
a scope of sinus  Evaluate total daily food - To establish a nutritional plan
bradycardia; with #7
intake. that meets individual needs.
PNSS 1L regulated @
 Provided NGT feeding with - This allows the patient to have
20cc/min with a side
drip of 90cc PNSS + strict aspiration precaution an intake to meet the
100mg Furosemide metabolic needs of the body.
regulated @ 30cc/hr;  Assess weight or calculate - To identify deviations from the
with D5W 46cc + body mass norm and to establish baseline
4mg Norepinephrine  Encourage use of sugar or parameters.
regulated @ 9cc/hr honey in beverages if - To establish nutritional plan
hooked at right carbohydrates are tolerated to meet the individual needs.
metatarsal vein
well.
infusing well; with
V/S: BP-90/80, P-43, DEPENDENT
R-12, T-37oC, O2-97%.  Administer pharmaceutical
Weight 41kg agents (digestive drugs, - May lead to early satiety.
enzymes, vitamins and
mineral, and medications)
as prescribed. - To promote wellness and
 Limit fiber or bulk, as meet individual needs.
indicated.
COLLABORATIVE
 Assist with providing oral
 care before and after - For patient’s comfort and to
meals. meet an individual’s need.
 Collaborate with
interdisciplinary team - To set nutritional goals when
client has specific dietary
needs, malnutrition is
profound, or long-term
feeding problem exist