Republic of the Philippines

WESTERN MINDANAO STATE UNIVERSITY

COLLEGE OF NURSING
Zamboanga City

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NURSING CARE PLAN

PLANNING
NURSING
ASSESSMENT OBJECTIVE OF IMPLEMENTATION EVALUATION
DIAGNOSIS INTERVENTION RATIONALE
CARE
SUBJECTIVE CUES Activity Intolerance At the end of the 8 Monitor and Vital signs and oxygen Monitored and After the 8 hours
Pt. complaints of related to Imbalance hours nursing evaluate the pt. saturation levels should be evaluated the pt. nursing intervention
persistent abdominal between Oxygen intervention, the response to monitored before, during, response to activities. the patient was able
discomfort, heartburn, Supply / Demand as patient shall be able activities. and immediately after to,
difficulty swallowing, evidenced by to, activity to determine
persistent cough. Shortness of Breath whether they are within the  Achieved a
at minimal exertion.  Achieve desired range. Heart rate measurable
Pt. notes an increase measurable should return to baseline increase in
swelling in her legs increase in within 3 minutes following activity
bilaterally, and mild activity the activity. Moderate tolerance.
substernal chest pressure. tolerance. continuous training is  Demonstrated
 Demonstrate efficient, safe, and well- the necessary
OBJECTIVE CUES techniques tolerated by HF patients, techniques or
Upon admission patient or behaviors and it is recommended by behaviors that
presented an episode of that enable the Heart Failure enables
sudden weakness and resumption Association Guidelines resumption of
shortness of breath. of activities. (Cattadori et al., 2018). activities.
 Participate  Participated in
Pt. had a history of in activities 6MWT is an exercise test Used the 6MWT to activities and
hypertension and and meet Consider the use of that entails measuring the determine the pt. meet own self
diabetes. own self the 6-minute walk distance walked over a physical ability. care needs.
care needs. test (6MWT) to span of 6 minutes (Enright,
Vital Signs determine the pt. 2003). It helps gauge the
T – 36.5C physical ability. patient’s cardiopulmonary
P – 98 b/m response. More
RR – 26 breaths/min information about the
BP – 210/100 mmHg 6MWT can be found here.
SPO2 – 92% room air
May denote increasing Evaluated the pt.
Laboratory Results Evaluate the pt. cardiac decompensation activity tolerance.
accelerating activity rather than overactivity.
Complete Blood Count intolerance. Three factors that affect the
 Leukocyte Count risk of exercise include
- 8,4000/mm3 age, heart disease presence,
with normal and exercise intensity (Piña
differential count, et al., 2003). Sudden
 Hemoglobin - cardiac death during
10.6g/dL, exercise is rare in
Hematocrit - apparently healthy
40%, individuals. Individuals
 Platelet Count - with cardiac disease seem
290,000/mm3 to be at a greater risk for
sudden cardiac arrest
Chemistries during vigorous exercise
 Glucose (such as jogging) than are
112mg/dL (non- healthy individuals
fasting) (Fletcher et al., 2001).
 BUN 33mg/dL Assisted the pt. in
 Creatinine Assist the pt. with Assisting with ADLs doing their self-care
1.6mg/dL self-care activities as ensure that the patient’s need.
necessary. And need is met while reducing
 Total Bilirubin
encourage cardiac workload. As much
1.9gm/dL
independence within as possible and as tolerated
 Direct Bilirubin
prescribed limits. by the patient, involve
0.3mg/dL
them in promoting a sense
 Total Protein of control and reducing
5.8g/dL helplessness.
 Albumin 3.1g/dL
Slow the pace of Allow the patient extra Planned a thorough
Electrolytes care and provide time to carry out physical care plan to avoid
 Sodium adequate rest before tasks, especially on exhaustion of the pt.
125mEq/L, and after periods of geriatric clients. Older
 Chloride exertion patients are more
93mEq/L, vulnerable to falls and
  Potassium injuries due to decreased
3.0mEq/L muscle strength, reduced
 Magnesium 1.5 balance, etc.
mg/dL
 Bicarbonate Intersperse activity periods Organized pt. nursing
23mEq/L Organize the pt. with rest periods by care activities within
nursing care developing a schedule that rest periods in between.
Blood test results for activities to allow promotes pacing and
cardiac peptide rest periods. prioritizes activities to
BNP or NT - meet the patient’s personal
proBNP levels were care needs without undue
higher than normal myocardial stress and
excessive oxygen demand
Urine: Specific Gravity (Cattadori et al., 2018; Piña
1.032, 1 plus protein, et al., 2003). Grouping
hyaline casts. nursing care allows
adequate time for the
patient to recharge.

Strengthens and improves Implemented a graded

Implement a graded cardiac function under cardiac rehabilitation
cardiac stress if cardiac program.
rehabilitation dysfunction is not
program. irreversible. Gradual
increase in activity avoids
excessive myocardial
workload and oxygen
consumption. Cardiac
rehabilitation offers an
effective model of care for
older patients with heart
failure (Austin et al.,
2005). The potential
benefit of increasing
exercise performance by
increasing training load
from moderate to higher
doses of exercise should be
weighed against the lack of
 an improvement in cardiac
vagal modulation and the
possible increase in the risk
of adverse events
(Volterrani & Iellamo,
2016). Adjusted the client’s
daily activities to
Adjust the client’s It prevents straining and tolerable ones to avoid
daily activities and overexertion, which may physiological and
reduce the intensity aggravate symptoms. Stop psychological changes.
of the level. all activity if severe
Discontinue shortness of breath, pain,
activities that cause or dizziness develops.
undesired Additionally, instruct the
physiological and patient or significant other
psychological to recognize the signs of
changes. overexertion. One way to
ensure the patient is not
overexerting during
physical ability is if they
can talk during the routine;
if they cannot do so,
decrease the intensity of
activity. Encourage the pt. to
rest.
Encourage patient to It relaxes the body and
have adequate bed promotes comfort.
rest and sleep; Temporary bed rest should
provide a calm and also be implemented
quiet environment. during an acute
exacerbation of heart Assisted the pt. during
failure symptoms. ambulation. Ascertain
Initiate interventions the patient’s ability to
and safeguards to stand and move about
promote safety and and degree of
prevent risk for assistance needed or
injury during use of movement aids
activity. or equipment.
 Motivated the pt. to
Encourage the client avoid distress on her
to maintain a It helps enhance the situation.
positive attitude; patient’s sense of well-
provide evidence of being and raises the
daily or weekly patient’s motivation and
progress. morale. Motivation is
necessary for patients with
HF who are attempting to
become more physically
active but may not be
sufficient to initiate
physical activity. In
addition to a high level of
motivation to be physically
active, patients with HF
must have a high degree of
self-efficacy (Klompstra et
al., 2018). Provide a
positive atmosphere during
the exercise regimen to
help minimize patient
frustration.