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ABAD, ROSETTE ANNE B.

BSN 301 – GROUP 1

NURSING CARE PLAN

NAME: R.O AGE: 56 Y/O GENDER: MALE

CUES NURSING ANALYSIS GOALS AND INTERVENTION RATIONALE EVALUATION


DIAGNOSIS OBJECTIVES
SUBJECTIVE CUES: Decreased Cardiogenic shock is a GOAL: After 8 hours of
 The patient cardiac output condition in which the After 8 hours of nursing nursing
stated, “Dinala R/T decreased heart can’t pump blood intervention, the patient intervention
ako rito sa RMC preload AEB sufficiently to attend its will able to have an
kasi sabi nung tachycardia metabolic needs adequate cardiac output
doktor sa health because of impaired like having a HR between
center sa amin contractility of the 60-80 bpm and a BP of
ay sobrang baba heart leading to 120/80 mmHg.
ng BP ko.” decrease cardiac
 He also stated output. Clients usually OBJECTIVES:
“Feeling ko manifest signs of low INDEPENDENT
mahihimatay cardiac output, with 1.) The patient will 1.) Discuss with the 1.) It will help the 1.) Does the
ako kasi parang adequate intravascular be able to know patient about his parent to be patient
nanghihina ako volume. It is usually about his disease, disease, its informed able to
at nahihilo.” associated its relevance to relevance of the about what’s know
with myocardial its nursing nursing going on to about his
OBJECTIVE CUES: infarction (MI), diagnosis, causes, diagnosis, causes, her child. disease, its
 BP: 70/30 cardiomyopathies, signs and signs and (Ref: Dawood, relevance
mmHg dysrhythmias, valvular symptoms, and symptoms, and O. (2010, Mar to its
 PR: 120 bpm stenosis, treatments. treatments. 5). Parent’s nursing
 RR: 35 cpm massive pulmonary Knowledge diagnosis,
 Temp: 35.5 embolism, and causes,
degrees Celsius cardiac surgery, or Management signs and
 O2 Sat: 89% cardiac tamponade. It of Their symptoms,
is a self-perpetuating Children’s and
condition Ailments in treatments
because coronary bloo Malaysia. ?
 Client looked d flow to Retrieved Yes:
pale and the myocardium is from: No:
cyanotic compromised, causing https://www. Why?
 Mottling of the further ischemia and ncbi.nlm.nih.g
skin ventricular ov/pmc/articl
dysfunction. es/PMC41330
62/)
Ref: Mayo Clinic Staff.
(2014, October 9). DEPENDENT:
Cardiogenic Shock. 2.) The patient will 2.) Provide 2.) Electrolyte 2.) Does the
Retrieved from be able to replace electrolyte imbalance patient
http://www.mayoclinic the loss replacement as may able to
.org/diseases- electrolytes in his prescribed. cause dysrhyt replace the
conditions/cardiogenic body. hmias or other loss
- pathological electrolyte
shock/basics/definition states. [Ref: s in his
/con-20034247 Martin, P. body?
(2017, Yes:
February 27). No:
Cardiogenic Why?
Shock.
Retrieved
from
https://nurses
labs.com/card
iogenic-shock-
nursing-care-
plans/2/]

3.) The patient will 3.) Administer IV 3.) Optimal fluid 3.) Does the
be able to replace fluids for clients status ensures patient
the fluids that with a decreased effective able to
were lost. preload. ventricular replace the
filling fluids that
pressure. Too were lost?
little fluid Yes:
reduces No:
circulating Why?
blood volume
and
ventricular
filling
pressures; too
much fluid can
cause
pulmonary
edema in a
failing heart.
Pulmonary
capillary
wedge
pressure
guides
therapy. [Ref:
Martin, P.
(2017,
February 27).
Cardiogenic
Shock.
Retrieved
from
https://nurses
labs.com/card
iogenic-shock-
nursing-care-
plans/2/]
4.) The patient will 4.) Administer 4.) Oxygen may 4.) Does the
able to have an oxygen as be required to patient
oxygen prescribed. maintain able to
saturation above oxygen have an
90%. saturation oxygen
above 90% or saturation
as indicated by above
order or 90%?
protocol. [Ref: Yes:
Martin, P. No:
(2017, Why?
February 27).
Cardiogenic
Shock.
Retrieved
from
https://nurses
labs.com/card
iogenic-shock-
nursing-care-
plans/2/]

5.) The patient will 5.) Administer 5.) Medication 5.) Does the
able to have a medicines as therapy is patient
systolic BP prescribed. more effective able to
greater than 90 when initiated have a
or 100 mmHg by early. The goal systolic BP
administering is to maintain greater
medications. systolic BP than 90 or
greater than 100 mmHg
90 or 100 mm by
Hg. [Ref: administeri
Martin, P. ng
(2017, medication
February 27). ?
Cardiogenic Yes:
Shock. No:
Retrieved Why?
from
https://nurses
labs.com/card
iogenic-shock-
nursing-care-
plans/2/]