NURSING CARE PLAN

ASSESSMENT NURSING PLANNING NURSING ACTION RATIONALE EVALUATION

DIAGNOSIS
Decreased Cardiac Short Term Goal: Assessed for and document the At the end of 7-hour
Objective Cues: Output related to At the end of 30- ff: Cerebral perfusion is Nursing Interventions,
Generalized CardioVascular min Nursing o Mental Status directly r/t cardiac the goal was partially
paleness Disorder Interventions, the output and aortic met as evidenced by:
noted client will be able perfusion pressure and is
Irregular to: influenced by hypoxia PR = 66
rhythm of Demonstrate and electrolyte and acid- BP=100/60
pulse noted hemodynamic base variation
Slowed stability (blood o Lung sounds Crackles may develop r/t Endorsed to the next
Capillary refill pressure and alterations in CAD shift NOD for further
Poor Skin cardiac output) o Blood Pressure Hypotension r/t interventions and
Turgor by 20% 30% as hypoperfusion, vagal revisions of NCP for
BP=90/60 revealed in the stimulation, continuity of care
PR = 60bpm cardiac monitor dysrhythmias, or
ventricular dysfunction
Long Term Goal: may occur
At the end of 7- o Heart Sound Bradycardia may be
hour Nursing present because of vagal
Interventions, the stimulation or
client will be able conduction disturbances
to: r/t area of MI
Demonstrate o Peripheral Perfusion Decreased may indicate
hemodynamic a decreased cardiac
stability (Blood output
pressure and -MSN, Black and Hawks,
cardiac output) Vol. 2, 7th edition
Maintain stable
BP of 100/80 Elevate Lower extremities above Facilitate oxygenation
the level of the heart. and proper circulation
-NANDA, Doenges,
Moorhouse, Murr, 11th
edition