Assessment Diagnosis Scientific Basis Planning

Subjective: Actual problem: Patient’s with HF have difficulty Goal:

maintaining adequate
" Naguol ko kay
oxygenation, they are likely
daghan man ang
Anxiety r/t After 6° of nurse-client
gina-dili sa ako.” As to be restless and anxious and interaction, the patient
breathlessness
verbalized. feel overwhelmed by
and restlessness will describe a reduction
from inadequate breathlessness. These in the level of anxiety
oxygenation symptoms experienced.
Objective:
tend to intensify at night.
>irritability noted Emotional stress stimulates
>weakness noted the sympathetic nervous
system
>fatigue
which causes vasoconstriction,
elevated arterial pressure, and
increased heart rate. This
sympathetic response
increases the cardiac workload.

- Med. Surg. 11th edition by

Brunner & Suddarth
 Intervention
Independent Nursing
Interventions:
1. Assess patient’s level of
anxiety.
2. Determine how the patient
copes with anxiety.
Rationale Evaluation
The goal was met:
• Mild anxiety enhances the The patient described a
patient’s awareness and ability to reduction in the level of
identify and solve problems. anxiety experience.
Moderate anxiety limits awareness of
environmental stimuli. Problem
solving can occur. But maybe more
difficult and the patient may need
help. Severe anxiety decreases the
patient’s ability to integrate
information and solve problems.
With panic, the patient is unable to
follow directions. Hyperactivity,
agitation and immobilization maybe
observed.
• This can be done by
interviewing the patient. This
assessment helps determine the
effectiveness of coping strategies
currently used by the patient.
 Assessment Diagnosis Scientific Basis Planning

Heart failure is the inability of

the heart to pump sufficient
Subjective: Actual problem: Goal:
blood to meet the oxygen
" Dali ra ko demands of the tissues. It is
malipong", as
Decreased cardiac the only major cardiovascular After 6 ° of nursing
verbalized. condition whose incidence
output r/t interventions the patient
decreased preload continues to rise in the world. It will maintain
is the final syndrome of wide
compensated cardiac
spectrum of endothelial &
output.
myocardial injuries to produce
Objective:
ventricular systolic dysfunction
(poor pumping function) and
diastolic dysfunction (poor
➢ increased
relaxation function). Patient is
blood pressure
classified based on the
➢ increased
symptoms. Class II, patient
heart rate
experience slight limitations in
➢ cold clammy
their physical activity. Class III,
skin
patient experience marked
limitation of their therapy for
heart failure are to improve
cardiac output, reduce cardiac
workload, prevent
complications, recognize early
signs of decompensation &
improve quality of life.

-Nursing Care plans by

Gulanick/ Myers6th edition
©2007
 Assessment
Intervention Diagnosis Scientific Basis
Rationale Planning
Evaluation

Independent Nursing Actual problem:

Subjective: Congestive heart failure (CHF), Goal:
Goals was partially met: No
Interventions: or heart failure, is a conditionshortness of breath noted,
“Nanghupong man After 8° of nursing
in which the heart can't pump reduced edema from the
ako tiil”, as interventions, patient
Excess fluid• Sinusenough
tachycardia & increase
blood to the body's extremities
verbalized.
1. Assess heart rate &volume
blood r/tarterial BPother will maintain adequate
are seen in the
organs. Theearly
"failing"
pressure. fluid volume and
decreasedstages,
renal BPheart
dropskeeps
as theworking
condition but not as
electrolyte balance, clear
perfusion deterioratesefficiently as it should. People
lung sounds, absent
with heart failure can't exert
Objective: pulmonary congestion,
themselves because they
and resolution of edema.
• Cold clammy
become skin
short isofsecondary
breath and
2. Assess skin color &
to compensatory
tired. As increase
blood flow in out of the
temperature.
➢Edema noted 2+ sympathetic nervous
heart slows,system
blood returning to
stimulationthe& low
heart cardiac
through output &
the veins
desaturation.
backs up, causing congestion
➢Bounding pulse in the tissues. Often swelling
(edema) results. Most often
• The failing
there'sheart mayin
swelling not belegs and
the
able to respond
ankles, tobut
increased oxygenin
it can happen
3.Shorteness
➢ of
Provide oxygen as demand. Oxygen supply
other parts maybe
of the body, too.
breath
indicated by the patient’s inadequate when there
Sometimes is fluid
fluid collects in the
condition & saturation levels accumulationlungsin and
the lungs.
interferes with
breathing, causing shortness of
➢Oliguria breath, especially when a
• This reduces preload &
person is lying down.

– http://www.thrifthomeca
re.com/patientcaregivers
.asp?issue=chf
 Intervention Rationale Evaluation

Independent Nursing Goals was partially met:

Interventions:

• This can help guide

1. Obtain patient history to
ascertain the probable cause
of the fluid disturbance.
2. Assess for crackles in
lungs, changes in respiratory
pattern, shortness of breath,
or orthopnea.
Patient maintained adequate
interventions. History may include
fluid volume and electrolyte
increased fluids or sodium intake, or
balance as evidenced by vital
compromised regulatory
signs within normal limits,
mechanisms.
clear lung sounds, pulmonary
congestion absent on x-ray
and resolution of edema.
• These early signs of pulmonary
congestion from fluid overload.

3. Monitor input and output

closely
• Although overall fluid intake
may be adequate, shifting of fluid out
of the intravascular spaces may
result in dehydration.

• This increases venous return

4. Elevate edematous and in turn decreases edema.
extremities
Assessment Diagnosis Scientific Basis Planning
 Subjective: Actual problem: Shortness of breath is one Goal:
classic symptom of congestive
heart failure, one of the After 8°of nursing
“Magmata2x ko kay Disturbed sleep nation’s most common—but interventions, the
naglisud man ko ug pattern r/t underpublicized—serious patient will be able to
ginhawa” as shortness of medical conditions. verbalize improvement
verbalized by the breath CHF develops when, after in hours and quality of
patient. many years of being sleep.
overworked, your heart begins
to poop out. It keeps pumping,
but not as well as it should. As
Objective:
CHF develops, your blood flow
➢ Fatigue slows. Your tissues don’t get
the oxygen they need. Your
body tries to compensate by
increasing your rate of
➢ frequent daytime breathing, which is one reason
dosing why shortness of breath cause
disturb sleep pattern.

➢ irritability
http://www.heal.com/congestiv
e-heart-failure/chf-symptoms-
causes
➢ Interrupted sleep
 Intervention Rationale Evaluation

Independent Nursing Goals was met:

Interventions:

• This measure need to awaken Patient verbalizes

to void. improvement in hours and
1. Instruct patient to avoid quality of sleep.
fluid intake before bedtime.

2. Encourage patient to
follow bedtime rituals and • This is known to promote
avoid caffeine and smoking. relaxation.

3. Encourage patient to
elevate head with two pillows.

4. Decrease daytime • Elevating the head of the bed

napping. can reduce pulmonary congestion
and night time dyspnea.

• Decreasing daytime sleep will

help patient be tired enough to sleep
 Assessment Diagnosis Scientific Basis Planning

The heart interacts with the

Subjective: Actual problem: arteries and veins that make Goal:
up the circulatory system by a
“Kapuyan man ko network of nerves that make
molihok” as up the autonomic nervous
Activity After 4 ° of nursing.
verbalized by the system. The autonomic
intolerance r/t Interventions, patient
patient. nervous system receives and
decreased cardiac will be able to report
output processes information from improve activity
body sensors in multiple sites tolerance within
Objective:
and organs and relays this capabilities.
information to the brain. The
brain decides what to do and
➢ Fatigue
sends signals to the heart,
arteries, and veins
automatically. Two major
➢ inability to
branches make up the
perform activity
autonomic nervous system.
The parasympthetic nervous
system is responsible for rest
➢ exertional activities such as the digestion
discomfort or of food and the slowing of the
dyspnea heart rate with relaxation. The
sympathetic nervous system is
responsible for gearing the
body up for exertion or "fight
or flight" types of activity. The
sympathetic nervous system
plays an important role in HF.

– http://www.txai.org/edu/
hrtdisease/heart_failure.
htm
 Intervention Rationale Evaluation

Independent Nursing Goal was met:

Interventions:
• Motivation is enhanced if the
patient participates in goal setting.
Patient reports activity
Depending on the classification of
tolerance within capabilities.
HF, some class I or II patients may be
1. Establish guidelines and
able to successfully work outside the
goals of activity with the
home on part-time or full-time basis.
patient and significant others. Patient reports ability to
However, other patients may be
perform required activity of
class III or IV and be relatively
daily living.
homebound.

• This aids in defining what the

2. Assess the patient level
patient is capable of, which is
of mobility.
necessary before setting realistic
goals.

3. Use slow progression of • Slow progression prevents

activity (e.g. walking in a sudden increase in cardiac workload.
room, walking short distances
around the house, and then
progressively increasing
Assessment Diagnosis Scientific Basis Planning
Subjective: Actual problem: Pulmonary congestion occurs Goal:
when the left ventricle cannot
After 8 hours of nursing
effectively pump blood out of
interventions, the
Impaired gas the ventricle into the aorta and
patient will demonstrate
exchange r/t the systemic circulation. The
improve ventilation and
altered oxygen increased left ventricle end-
adequate and oxygen
supply cause by diastolic blood volume
supply and absent of
Objective: the underlying increases the left ventricular
symptoms of respiratory
pulmonary and diastolic pressure, which
distress.
condition decreases blood flow from left
Dsypnea on atrium into the left ventricle
exertion during diastole. The blood
Orthopnea volume and pressure in the left
atrium increases, which
Paroxysmal decreases blood flow from the
nocturnal dyspnea pulmonary vessels. Pulmonary
venous blood volume and
Bilateral crackles
pressure increase, forcing fluid
that do not clear
from the pulmonary capillaries
with cough
into the pulmonary tissues and
Cough on exertion alveoli, causing pulmonary
or when supine interstitial edema and impaired
gas exchange.
 Intervention Rationale Evaluation

Independent Nursing
Interventions:
1. Elevate head of
bed/position client
appropriately.
2. Encourage frequent
changes and deep
breathing/coughing exercises.
The goals was partially met:
• To maintain airway.
Client slightly improved
ventilation and oxygen
supply.
• Promotes optimal chest expansion
and drainage of secretions.

3. Encourage adequate rest • Helps limit oxygen

and limit activities to within needs/consumption
client tolerance. Promote
calm/restful environment.

4. Administer medications
as indicated. • To treat underlying conditions.

5. Keep environment
allergen/pollutant free.