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ROOM #: 306 ASSESSMENT Subjective: Nahihirapan akong huminga as verbalized by the patient Objective: -O2 sat: 97 -RR: 18 -Lung

sound: Vesicular breath sound -Hemoglobin: 9.9 -capillary refill: > 3 seconds -Pale -With oxygen cannula 1L/min NURSING DIAGNOSIS 1.Altered breathing related to inadequate tissue perfusion secondary to decreased in hemoglobin RATIONALE Decreased hemoglobin level PLAN OF CARE After 5 hours of nursing of nursing intervention the patient will: INTERVENTION 1.Positioned the client to semi-fowlers position RATIONALE 1.Positioning the client in a semi-fowlers position will help the client to relax tension of the abdominal muscles, allowing for improved breathing and to increase comfort during eating and other activities EVALUATION

Decreased oxygen supply to the cells

Inadequate tissue perfusion

Difficulty of breathing

2.administered O2 1L/min 2. used to decrease as ordered work of breathing by increasing alveolar oxygen tension. 3.encourage complete bed rest 4. Provided calm environment 3.

Auscultate apical 2. Decreased cardiac output related to altered myocardial contractility /inotropic changes. Chronic heart failure pulse; assess heart rate, Inadequate cardiac output to meet the metabolic needs of the body and rhythm. Inspect skin for pallor, Increase heart rate (as a compensatory mechanism to increase cardiac output) cyanosis. Monitor urine output, noting decreasing Vasoconstriction to maintain blood pressure output and dark or concentrated urine. Increased preload and afterload that contribute to chamber dilation (hypertrophy) Administer supplemental oxygen as indicated.

Worsening heart failure

Tachycardia is usually present even at rest to compensate for decreased ventricular contractility. Pallor is an indicative of diminished peripheral perfusion secondary to inadequate cardiac output, vasoconstriction, and anemia. Cyanosis may develop in refractory heart failure. Dependent areas are often blue or mottled as venous congestion increases. Urine output is usually decreased during the day because of fluid shifts into tissues but may be increased at night because fluid returns to circulation when

patient is recumbent.

Notes: Hypertrophy is the increase in the volume of an organ or tissue due to the enlargement of its component cells. It should be distinguished from hyperplasia, in which the cells remain approximately the same size but increase in number