Care Plan

ASSESSMENT

(Cluster Data)

NURSING DIAGNOSIS

(Prioritized by Maslow)

(List Source/Page #)

OBJECTIVES

(Desired Outcomes/Goals)

Must be measurable.

List 2:

EVALUATION

( Outcome Criteria)

Overall evaluation statements of goal. Met, partially met, not met. Include criteria AEB if partially or not met.

C =midsternal chest pain, described as crushing pain, rated 7/10. No precipitating or alleviating factors noted.

Temp 98.3 orally. WBC 9.4

O=Hx of asthma. No complaints of SOB or restlessness. Respiratory rate 20, regular, no use of accessory muscles or nasal flaring. Bronchodilator inhaler PRN. ABG pH 7.33, pCO2 49, HCO3 24. Hx of chest pain. Medication-Hydrochlorothiazide daily. Pulse irregular, weak, rate 106. BP 98/56.

N=Hx GERD, wears dentures, skin dry and intact. Medication-Zantac daily

C=No communication deficits noted.

E=urine yellow and clear, patient denies prostate problems. Last BM yesterday, formed and brown.

P=married, two grown children. Approaching retirement and looking forward to that. Denies hx of anxiety and depression.

T=memory intact, alert, receptive to learning about health changes, worried about complexity of treatment.

S=wears glasses, steps to enter home. Bathroom on the first floor. Full ROM noted.

1. Impaired cardiac output r/t altered contractility AEB weak irregular pulse

2. Impaired gas exchange r/t altered oxygen supply AEB abnormal ABGs

3. Lack of knowledge r/t complexity of treatment AEB verbalizing inaccurate information

1. Patient will have adequate cardiac output as evidence by HR 60-100 with regular rhythm within 24 hours.

2. **You are only required to have one goal for the #1 dx. If you add a second one, you will need 3-4 additional interventions.

1. Goal met, HR evaluated every 2 hours with a range of 68-80. Pulse is regular without weakness.

2. **Only needed if there is a second goal.

Nursing Actions:

(Interventions)

1. Assess peripheral pulses, including capillary refill

Rational: pulses are weak with reduced stroke volume and cardiac output. Capillary refill is slow, sometimes absent.

2. Administer oxygen therapy as prescribed.

Rational: The failing heart may not be able to respond to increased oxygen demands. Oxygen saturation needs to be greater than 94%.

3. Treat dysrhythmias according to medical orders or protocol, and evaluate response.

Rationale: Both tachydysrhythmias and brady dysrhythmias can reduce cardiac output and myocardial tissue perfusion.

4. Assess for the presence of S3 and S4 heart sounds.

Rationale: S3 denotes reduced left ventricular ejection and is a classic sign of left ventricular failure. S4 occurs with reduced compliance of the left ventricle, which impairs diastolic filing.

Evaluation:

(Evaluate Patients response to EACH action)

1. Radial and pedal pulses palpated, equal bilaterally. No weakness or irregularity noted. Capillary refill for fingers and toes were less than 3 seconds.

2. Oxygen 3L NC maintained, no SOB noted. Pulse ox 95%.

3. Telemetry maintained, no dysrhythmias noted. Apical pulse regular, rate 72.

4. No presence of S3 or S4 noted during apical auscultation.