Nursing

Problem or Cues Objectives Interventions Rationale Evaluation

Diagnosis

SUBJECTIVE Decreased Monitor for

CUES: Nahihirapan Cardiac Output After 8 hours of As these After 8 hours of
symptoms of
ako huminga as nursing heart failure symptoms of nursing
verbalized by the interventions the and decreased heart failure interventions, the
patient. patient will able output, progress, patient
to demonstrate including cardiac demonstrated
adequate cardiac diminished output adequate cardiac
OBJECTIVE CUES: output as quality of declines. output as
- Altered heart evidenced peripheral evidenced by
rate by blood pulses, cool blood pressure and
(Arrhythmia) pressure and skin and pulse rate, rhythm
- Palpitations pulse rate and extremities, within normal
- Fatigue rhythm within increased parameters; strong
- Edema normal respiratory peripheral pulses;
- Shortness of parameters; rate, presence and ability to
breath strong peripheral of paroxysmal tolerate activity
- Oliguria pulses; and an nocturnal without symptoms
- Prolonged ability to tolerate Dyspnea or of Dyspnea,
capillary refill activity without orthopnea, syncope or chest
- BP: 160/100 symptoms of increased pain.
- PR: 135 bpm Dyspnea, heart rate.
syncope, or Listen to heart The new
chest pain. sounds; note onset of a
rate, rhythm, gallop
presence of rhythm,
S3, S4 and tachycardia,
lung sounds.
and fine
 crackles in
lung bases
can indicate
Observe for onset of
confusion, heart failure.
restlessness, CNS
agitation, disturbance
dizziness.
may be
noted with
decreased
Observe for cardiac
chest pain or output.
discomfort; Chest
note location, pain/discomf
radiation, ort is
severity, generally
quality, indicative of
duration, an
associated inadequate
manifestation blood supply
such as nausea to the heart,
and
which can
precipitating
and relieving compromise
factors. cardiac
Administer output.
oxygen as To relieve
needed per shortness of
Physicians breath
order.
Place client in Elevating the
semi-Fowlers head of the
position or bed may
position of decrease the
comfort. work of
breathing,
and also
decrease
venous
return and
preload.