ASSESSMENT Subjective: mabilis pero mahina na ang pulso niya at nahihrapan na siya huminga as verbalized by the significant toher

of the patient. Objective: Dyspnea(slow shallow breathing). Crackles Bipedal Edema Jugular vein distention Dyspnea(slow shallow breathing) Capillary refill 5 secs.

DIAGNOSIS Decreased Cardiac Output related to left ventricular dysfunction and dysrhythmias.

PLANNING Short Term Goal:

INTERVENTIONS Independent: Obtained vital signs every 15 minutes during acute phase. Assessed for skin warmth, color, and capillary refill time. Assessed for chest discomfort

RATIONALE To able to supervise changes that can worsen the patient condition. To know the oxygen status of the patient Myocardial ischemia may result from poor perfusion. To minimize oygen demand. To be able to know cardiac status of the patient. To know the oxygen saturation status.

EVALUATION After 2 hours of nursing intervention the client had able to have an improve cardiac output.

After 2 hours of nursing intervention the client will be able to have an Inference: improved cardiac output. Occlusion upon the . blood vessels Long Term Goal:

Less oxygen

impaired systolic dysfunction

After 1 month of hospitalization the client the client will be able to have improved wellness.

dysrhythmias.

Have the client to have an adequate rest. Analyzed ECG rhythm strip at least every 4 hours and note rate. Continuously monitor oxygen status with pulse oximetry.

Vital Signs: PR: 120 bpm(irregular rhythm) RR: 30 cpm myocardium is weakened

DECREASED CARDIAC OUTPUT Laboratory: Oxygen Saturation:88% Reference: Medical and surgical Nursing by brunner.

Monitor serum potassium before and after administration of loop diuretics. Dependent: Administered cardiac medications as ordered. Administered diuretics as prescribed. Collaborative: Assisted in echocardiography

To prevent the risk of hypokalemia.

To prevent further complications and to solve underlying problems. To reduce fluid overload. To know the cardiac status of the patient.