1.

Decreased Cardiac Output

Assessment Nursing Desired Nursing Interventions Rationale Evaluation: Goal

Data Diagnosis Outcomes/ & Interventions
Client Goals
Subjective Decreased Client will display 1. Monitor BP 1. BP may be elevated Goal met. Client
Data: Cardiac Output hemodynamic 2. Monitor urine output, because of increased SVR; hemodynamic
Pte states that he related to parameters within noting decreasing output the body may no longer within acceptable
is short of breath altered acceptable limits and dark or concentrated compensate. limits. Will
and feeling weak. myocardial and urinary urine. 2. Kidneys respond to continue to
Pte states feeling contractility as output within 3 3. Inspect skin for pallor reduce cardiac output by monitor
very dizzy and evidence by days. and cyanosis. retaining water and sodium. hemodynamic for
waking up at increase in BP 4. Anti-anxiety agent and 3. Pallor is indicative of any changes.
night coughing (161/91) and a Client will sedative, as indicated. diminished peripheral
with a feeling of decrease participate in 5. Monitor and replace perfusion secondary to Goal met. Client
suffocation. ejection fraction activities that electrolytes, as indicated inadequate cardiac output, reports no sign of
of 20 – 25%. reduce cardiac 6. Administer Medication vasoconstriction, and overexertion at
Objective Data: workload by as indicated by MD. anemia. discharge.
Pte has discharge. 4. Promotes rest and Provided pte with
orthopnea and relaxation, reducing oxygen instructional
paroxysmal demand and myocardial pamphlets on how
nocturnal workload. to reduce cardiac
dysnea. 5. Fluid shifts and use of workload.
Pte has pallor diuretics can alter
and is observed electrolytes, which affect
having a difficult cardiac rhythm and
time catching his contractility.
breath and has 6. A variety of medication (a
an altered LOC. combination of diuretics, an
Pte skin is cool ACEI or ARB and Beta
and dry (ashy). Blocker) may be used to
Pte has abnormal increase stroke volume,
Labs. improve contractility, and
Pte has reduce congestion.
decreased EF of
20 – 25%, O2 Sat
90%, PO2 62.9
and increase in
BP (161/91)
2. Excess Fluid Volume

Assessment Nursing Desired Nursing Interventions Rationale Evaluation: Goal

Data Diagnosis Outcomes/ & Interventions
Client Goals
Subjective Excess Fluid Client will 1. Monitor urine output. 1. Urine output may be Goal met. Client
Data: Volume related demonstrate 2. Change position scanty and concentrated reports that it isn’t
Pte states feeling to decreased stabilized fluid frequently. because of reduce renal as hard to be on a
very dizzy and glomerular volume with 3. Administer Medication perfusion. fluid restriction.
waking up at filtration as balanced intake as indicated by MD. 2. Edema formation, slowed Continue to
night coughing evidence by and output within (Lasix) circulation, altered monitor and
with a feeling of respiratory 3 days. nutritional intake, and document fluid
suffocation. distress (PO2 prolonged immobility are intakes.
62.9 & O2 Sat Client will cumulative stressors that
Objective Data: 90%). verbalize affect skin integrity. Goal in progress.
Pte has abnormal understanding of 3. Increases rate of urine Pte correctly
Labs how to monitor flow and may inhibit identifies that
– BUN 140 weight changes reabsorption of Na and Cl in monitoring his
– Creatinine by discharge. the renal tube. weight every
2.2 morning is the
– O2 Sat 90% most effective way
– PO2 62.9 to indicate fluid
– BP (161/91) overload.

3. Unstable blood Glucose Level

Assessment Nursing Desired Nursing Interventions Rationale Evaluation: Goal

Data Diagnosis Outcomes/ & Interventions
Client Goals
Subjective Unstable blood Client will 1. Perform finger stick 1. All available glucose Goal met. Client
Data: glucose level maintain glucose glucose testing monitors will provide maintained
Pte states feeling related to within satisfactory 2. Observe for signs of satisfactory readings if satisfactory
very dizzy and changes in range within 48 hypoglycemia properly used and glucose range
increased thirst. physical health hours. 3. Monitor lab studies maintained. within (75 – 115).
 status as 2. Once carbohydrate Provided Pte with
Objective Data: evidence by metabolism resumes, blood instruction on
Pte has abnormal altered level of glucose level will fall, and as lifestyle change
Labs consciousness. insulin is being adjusted, and modifications
– Glucose 214 hypoglycemia may occur. to maintain
– Ketones (+) 3. Blood glucose will glucose levels
Pte has altered decrease slowly with within satisfactory
LOC. controlled fluid replacement levels.
Polyphagia, and insulin therapy. With the
polyuria administration of optimal
insulin dosage, glucose can
then enter the cells and be
used for energy.