ASSESSMENT

Subjective cue: luya na kaau ko dong-ubos na kayo ako BP as verbalized

NURSING DIAGNOSIS Decreased Cardiac Output related to altered heart contractility secondary to RHD

SCIENTIFIC ANALYSIS Any illness or injury has a direct effect on the heart can produce a decrease in cardiac output. Such disorders include cardiac dysrhythmias, acute myocardial infarction , cardiac injury, cardiac tamponade and cardiac infection or myopathy. When cardiac output decreases, tissue perfusion adversely affected. Therefore any disease process that produces a reduction in stroke volume or an alteration in heart rate has a direct effect on cardiac output. Med.-surgical nursing 8th ed. Black,vol. 2 page 2203

NURSING OBJECTIVES After 8 hrs of holistic nursing care patient will improve cardiac output as evidenced by patient will: >demonstrate decrease episodes of dysnea >increase activity tolerance >improve blood pressure to desired range of 100120/80-90 mmHg >increase pulse rate to normal range

NURSING INTERVENTION Independent: Established rapport

RATIONALE

EVALUATION

.- to provide trust and confidence -baseline data and facilitates improvement on interventions provided -prevent occurrence of shock -reduce cardiac workload

Monitored vital signs

Objective cues: >cold clammy skin extremities >skin pallor >dyspnea >clubbing of fingers noted >BP:90/60mm Hg >weak pulses noted >PR: less than 60 bpm = range of 5357 bpm upon assessment >agitation noted >decrease activity tolerance

Assessed signs of hypovolemia Position patient on semi-to high fowlers position Assisted patient in self-care activities Encouraged to breathe deeply in & out during activities not to hold breathe.

After 8 hrs of holistic nursing care patient demonstrated decreased episodes of dyspnea, increased in activity , improved blood pressure range of 100/80 mmHg ,increased pulse rate to 60 -65 bpm.

-to avoid exhaustion of the patient -reduces cardiac workload, prevent valsalva response

Dependent: Administered Oxygen -to maximize oxygen available to tissues

Administer drugs as ordered.

-to prevent complications

Encouraged to maintain fluids minimum of 1L/day as ordered Collaborative: Report any unusualities in cardiac monitor.

-to prevent dehydration

-facilitates to other health care provider for better improvements