ASSESSMENT DIAGNOSIS SCIENTIFIC OBJECTIVE INTERVENTIONS RATIONALE EXPECTED

EXPLANATION OUTCOME
S- O Decreased When the blood Short Term: > Assess the patient’s > To be able to establish a Short Term:
O> cardiac output pressure is high, it After 8 hours condition baseline data The patient
Patient manifested related to puts stress on the of nursing shall have
• Blood altered preload heart to pump interventions, displayed
pressure of (decreased faster, when the the patient will > Evaluate client’s > To assess for signs of poor hemodynamic
• 11/27/19 – venous return) heart pumps faster, be able to reports/evidence of extreme ventricular function and or stability as
140/70 as evidenced by its contraction display fatigue, intolerance for impending cardiac failure evidenced by
• 11/28/19 – increased blood strength lessens. hemodynamic blood pressure
activity, sudden or
140/80
pressure of This can result to stability as progressive weight gain, within normal
• 11/29/19 –
130/80 140/70mmHg increase peripheral evidenced by swelling of extremities, and limits.
• Mitral and vascular resistance. blood pressure progressive shortness of
aortic If the heart contracts within normal breath Long Term:
sclerosis faster, its oxygen limits. The patient
• Weakness consumption also shall have
• Vital signs are
as follows: increases when the Long Term: > Review diagnostic such demonstrated
> Helps determine underlying
• T: 36.0 artery going to the After 3 days of as blood chemistry an increase in
cause
• P: 74 heart cannot supply nursing activity
• R: 24 the oxygen demand interventions, tolerance
of the heart plus the the patient will without
Patient may > Keep client on bed or > Decreases oxygen
presence of be able to symptoms of
manifests: chair rest in position of consumption and risk of
• Chest pain abnormality of the demonstrate dyspnea,
comfort decompensation
• Jugular vein blood vessel will an increase in syncope or
distention result to chest pain. activity chest pain.
• Edema > Decrease stimuli; provide > To promote adequate rest
The patient’s tolerance
• Weight gain quiet environment
diagnosis is chronic without
symptoms of
 kidney disease, this dyspnea, > Administer low-flow (1-2 > To increase oxygen availability
can decrease the syncope or pm) of oxygen mask or for cardiac function/tissue
cardiac output chest pain. ventilator as prescribed the perfusion
because there is a doctor
decreased
production of > Encourage relaxation > To reduce anxiety
erythrocyte brought techniques such as deep
about by the breathing exercise
disease process.

Problem no. 1: Decreased cardiac output related to altered preload (decreased venous return) as evidenced by increased blood pressure of
140/70 mmHg