Problem: Pallor associated with bodyweakness

Pathophysiology: Failure of the left and/or right chambers of the heart results in insufficient output to
meet tissue needs and causes pulmonary and systemic vascular congestion

Cues Nursing Diagnosis Objectives Interventions Rationale

Subjective: Decreased cardiac After 4 hours in 1.Auscultate apical 1.Tachycardia is

SO of patient output related to effective nursing pulse; asses heart usually present,
verbalized ”luspad altered interventions, rate, rhythm even at rest, to
siya ug dali ra siya myocardial patient will report compensate for
decreased
kapuyon . di siya contractility decreased
ventricular
ganahan nga episodes of contractility. PACs,
maglihok kay weakness, PAT, MAT and atrial
maghangos daw dyspnea, and fibrillation are
siya” participate in common
activities that dysrhythmias
Objective: reduce cardiac associated with
 Received workload heart failure
patient lying
2.Note heart 2.S1 and S2 may be
on bed with
sounds weak because of
ongoing IVF
diminished pumping
#2 D5W action. Gallop
regulated at rhythm are
KVO hooked common, produces
at left arm as blood flows into
infusing well non-compliant
with O2 chambers
attached via
nasal 3.Palpate 3. Decreased cardiac
peripheral pulses output may be
cannula
reflected in
@2L/ min diminished radial,
popliteal, dorsalis
 Body pedis. Pulses may
malaise be fleeting or
noted irregular to
 Pallor noted palpation, and
 Dyspneic pulsus alternas may
upon major be present
activities
4.Monitor BP 4.In earthy,
 V/S taken as
moderate or chronic
follows HF, BP may be
T: 36.2 °C elevated because or
P: 110 increased SVR.
R: 35
BP:80/60 5.Inspect skin for 5.Pallor is indicative
pallor , cyanosis of diminished
peripheral perfusion
 secondary to
inadequate cardiac
output,
vasoconstriction,
and anemia.
Cyanosis may
develop in
refractory HF

6.Monitor urine 6.Kidneys respond

output, noting to reduced cardiac
decreasing output output by retaining
and dark, water and sodium
concentrated urine
7.May indicate
7.Note changes in inadequate cerebral
sensorium, e.g. perfusion secondary
lethargy, confusion to decreased
disorientation, cardiac output
anxiety
8.Physical rest
8. Encourage rest, should be be
semi recumbent maintained during
bed or chair. acute or refractory
HF to improve
Assist as indicated efficiency of cardiac
9.Provide bedside contraction
commode
9.Commode use
10.Elevate legs, decreases work of
avoiding pressure getting to bathroom
under knee. or struggling to use
Encourage active / bedpan.
passive exercises
10.Decreases
venous stasis, and
may reduce
incidence of
thrombus or
embolus formation.

11.Check for calf 11.Reduced cardiac

tenderness; output, venous
diminished pedal pooling / stasis and
sounds; local enforced bedrest
redness, or pallor of increased risk of
extremity thrombopheebitis
 CUES NURSING PLAN INTERVENTIONS RATIONALE
DIAGNOSIS

P- difficulty of breathing Impaired gas After 8 hrs of 1. note respi. Rate 1. tachypnea and
exchange r/t holistic nursing and depth, work of dyspnea accompany
breathing ( use of by pulmonary
altered oxygen care the pt. will accessory muscles/ obstruction, dyspnea
S- “ maglisod ko og
supply as be able to nasal flaring, and increased work of
ginhawa “ as
evidence by demonstrate pursed-lip breathing maybe first
verbalized by the pt.
breathing) or only sing of sub-
O- dyspnea improve
acute pulmonary
 Received secondary to ventilation and embolus
patient lying on CHF adequate
bed with oxygenation of 2. auscultate lungs 2. non ventilated may
ongoing IVF #2 for area of be identified by
tissues by ABG’s
D5W regulated dec./absent breath absence of breath
at KVO hooked oximetry and to sounds and the sounds; crackles
at left arm be free from presence of occur in fluid filled
infusing well symptoms of adventitious sounds tissues/ airways or
(eg. Crackles) may reflect cardiac
with o2 respi. distress
decompensation
attached via
nasal cannula 3. monitor v/s. 3. Tachycardia,
@3L/min note change in tachypnea. And
cardiac rhythm. changes in BP. Are
 dyspneic with associated with
RR of 35 cpm advancing
hypovolemia and
acidosis. Rhythm
 restlessness alterations and extra
noted heart sounds may
reflect increased
cardiac workload r/t
worseningventilation
 labored imbalance.
breathing, uses
accessory 4. assess 4. systemic
muscle in breathing LOC/mental hypoxemia may be
changes demonstrated initially
 difficulty in by restlessness and
vocalizing irritability, then by
progressively
decreased mentation
 V/S taken as
follows
5. assess activity 5. these patameters
T: 36.2 °C tolerance; assist in determining
P: 110 encourage rest client response to
R: 35 periods, and limit resumed activities
BP:80/60 activities to client and ability to
tolerance participate in self care
6. elevate the head 6. promote maximal
of the bed as client chest expansion,
requires/tolerates. making it easier to
breath and enhancing
physiologic/
psychologic comfort.

7. assist with 7. turning and

frequency changes ambulation enhance
of position and get aerations of different
client out of bed/ lung segments,
ambulated as thereby improving
tolerated oxygen diffusion

8. assist client to 8. feelings of fear and

deal with fear severe anxiety are
anxiety that may be associated with
present. inability to breathe
and may actually
increase oxygen
consumption/demand

9. provide 9. delivers moisture

supplemental to mucous membrane
humidification; and helps liquefy
secretions to facilitate
airway clearance.

10. administer 10.maximizes

supplemental available oxygen for
oxygen by gas exchange,
appropriate reducing work of
method breathing
 CUES NURSING PLAN INTERVENTION RATIONALE
Diagnosis

P: decrease cardiac Decreased After 8 hours of 1. Auscultate apical 1. Tachycardia is

output nursing pulse; usually present
cardiac output intervention the assess heart rate, even at rest to
SUBJECTIVE CUES: related to patient will and rhythm. compensate for
decreased
‘’no subjective altered display vital signs
ventricular
cues’’ myocardial within acceptable contractility
limits, 2. Inspect skin for
OBJECTIVE:
contractility dysrhythmias pallor, cyanosis. 2. Pallor is an
 Received controlled and indicative of
patient lying no symptoms of diminished
on bed with peripheral perfusion
failure.
ongoing IVF secondary to
#2 D5W inadequate cardiac
regulated at output,
KVO hooked vasoconstriction,and
at left arm anemia.
infusing well 3. Monitor urine Cyanosis may
with o2 output, develop in
attached via noting decreasing refractory heart
nasal cannula output and dark or failure. Dependent
@3L/min concentrated urine areas are often blue
or mottled as
 Cold venous congestion
clammy skin increases
noted
 dyspnea 3. Urine output is
4. Note changes in usually decreased
noted
sensorium. during the day
 Crackles
because of fluid
noted upon shifts into tissues
auscultation but may be
 V/S taken as increased at night
follows because fluid
T: 36.2 °C 5. Provide quiet returns to
P: 110 environment circulation when
R: 35 patient is
BP:80/60 recumbent.

4. May indicate
inadequate cerebral
perfusion
secondary to
6. Administer decreased cardiac
supplemental output.
oxygen as indicated

5. Psychological rest
help reduce
7. Administer emotional stress,
diuretics as which can produce
prescribed. vasoconstriction,
elevating BP
andincreasing heart
rate or work.

6. Increases
available oxygen for
myocardial uptake
to combat effects of
hypoxia or ischemia.

7. Diuretics, in
conjunction with
restriction of dietary
sodium and fluids,
often lead to clinical
improvement in
patients with heart
failure
 CUES NURSINGDIAGNOSIS PLAN INTERVENTION RATIONALE

P- body malaise Activity intolerance After 8 hrs. of 1. check v/s before 1. orthostatic
r/t imbalanced bet. holistic nursing and immediately hypotension can
after activity, esp. if occur with activity
Oxygen supply and care the pt. will pt. is receiving because of med.
S – “Luya kaau akong
demand as be able to vasodilators. Effect. Fluid shift or
lawas as verbalized
evidenced by reduce Diuretics or B- compromised
by the patient” blockers cardiac pumping
weakness and weakness and
fxn.
O– dysnea. maintain
mobility @ the 2. document 2. compromised
 Received highest possible cardiopulmonary myocardium/in
patient lying response to activity. ability to inc. stroke
level.
on bed with Note tachycardia, vol. during activity
ongoing IVF dysrythmias. may cause an
#2 D5W Dysonea. immecliate inc. in
Diaphoresis pallor. HR and oxygen
regulated at
demands. Thereby
KVO hooked
aggravating
at left arm weakness fatigue
infusing well
with o2 3. encourage rest 3. reduces
attached via initially. Thereafter, myocardial
nasal limit activity on workload/oxygen
cannula basis of pain/ consumption
@3L/min adverse cardiac reducing risk of
response. Provide complications
nonstress
 Body
divertional
malaise activities.
noted
 Cold clammy 4. instruct client to 4. Activities that
skin noted avoid increasing req. holding the
 dyspnea abdominal pressure breath and bearing
noted down (valsava’s
 V/S taken as maneuver) can
follows result in
T: 36.2 °C bradycardia
(temporarily
P: 110
reduced cardiac
R: 35
output) and
BP:80/60 rebound
tachycardia with
elevated BP.

5. provide 5. meets clients

assistance with self personal care
care activities as needs without
indicated. myocardial stress/
Interperse with rest excessive oxygen
periods demand.
6. assess for other
precipitators / 6. fatigue is a side
causes of effect of some
fatigue(treatment, meds.( beta-
pain, meds blockers,
tranquilizers and
sedatives.
7. evaluate
accelerating activity 7. may denote
intolerance increasing cardiac
decompensation
rather than over
activity
8. explain pattern
of graded inc.of 8. progressive
activity level, (eg. activity provides
Getting up to controlled demand
commode or sitting on the heart,
in chair, progressive increasing strength
ambulation and and preventing
resting after meals. over exertion

9. review s/sx
reflecting 9. Palpitations,
intolerance of pulse irregularities
present activity develop of chest
level or req. pain or dyspnea
notification of may indicate need
nurse/physician for changes in
exercise regimen or
medication.
10. implement
graded cardiac 10. Strengthen and
rehabilitation/ improves cardiac
fxn under stress if
activity program
cardiac dysfxn is
not irreversible.
Gradual increase in
activity avoids
excessive
myocardial
workload and
oxygen
consumption