V.

NURSING CARE PLAN

1ST PRIORITY
Nursing Diagnosis
Ineffective cardiac
tissue perfusion
related to reduced
coronary blood
flow.

Related drug
therapeutics
Captopril
Trimetazidine
Isosorbide
Mononitrate
Clopidrogrel

Related Lab
diagnostics
Chest x-ray
Electrocardiogr
am
Arterial Blood
Gases
Capillary refill

Short Term
Goal
After 8 hours of
nursing
intervention:
Patient will be
able to exhibit
no further
worsening/repet
ition of deficits
and maintain
maximum
tissue perfusion
to vital organs
as evidenced by
warm and dry
skin, present
and vitals
within patients
normal range,
normal ABGs
and absence of
chest pain.

Nursing
Interventions
1. Asses for
signs of
decreased
tissue
perfusion.
2. Check for
respiration
and absence
of work or
breathing.
3. Check
Hemoglobin
levels and
pallor,
quality of
pulse.
4. Promote
active/passiv
e ROM
exercises
5. Administer
medications
as prescribed
such as
antiplatelet
and antihypertensive
s.

Rationale
1.
2.
3.

4.

5.

Provides baseline
for future
comparison.
Ischemic pain may
result in respiratory
distress.
Low levels reduce
the uptake of
oxygen at the
alveolar-capillary
membrane and
oxygen delivery to
tissues.
To prevent venous
stasis and further
circulatory
compromise.
To facilitate
perfusion by
reducing blood
viscosity and
coagulation and to
reduce systemic
vascular resistance
and optimize cardiac
output and
perfusion.

Evaluation/
Outcome
After 8 hours of
nursing
intervention:
Patient was able
to:
To exhibit no
further
worsening/repetit
ion of deficits
and maintain
maximum tissue
perfusion to vital
organs as
evidenced by
warm and dry
skin, present and
vitals within
patients normal
range, normal
ABGs and
absence of chest
pain.

2ND PRIORITY

Nursing Diagnosis
Decrease cardiac
output related to
alteration heart rate,
rhythm and
conduction.

Related drug
therapeutics
Captopril
Trimetazidine
Isosorbide
Mononitrate

Related Lab
diagnostics
Chest x-ray
Electrocardiogram

Short Term
Goal
After 8 hours
of nursing
intervention:
Patient will be
able to
demonstrate
adequate
cardiac output
as evidenced
by blood
pressure and
pulse rate
within normal
parameters
and ability to
tolerate
activity
without
dyspnea or
chest pain.

Nursing
Interventions
1. Assess the patient
on the following:
a. Skin color
b. Alteration in
LOC
c. Heart rate and
Blood
pressure
1. Administer
cardiac
medications such
as ACE inhibitors.
2. Record intake and
output
3. Position patient in
semi to high
fowlers
4. Administer
oxygen as
prescribed.

Rationale
1.

2.
3.
4.

5.

Assessment is required
in order to possible
problems that may lead
to worsening of
condition. Pale skin is
secondary to compensate
low cardiac output.
Restlessness and
irritability reflected
decreased cerebral
perfusion. Tachycardia
and low BP is a response
to compensate reduced
cardiac output.
Assess patients
tolerance before giving
medication.
Reduced cardiac output
results in reduced
perfusion of the kidneys.
To reduce preload and
ventricular filling when
fluid overload is the
cause.
Failing heart may not be
able to respond to
increased oxygen
demands.

Evaluation/
Outcome
After 8 hours of
nursing
intervention:
Patient was able
to:
Demonstrate
adequate
cardiac output
as evidenced
by blood
pressure and
pulse rate
within normal
parameters and
ability to
tolerate activity
without
dyspnea or
chest pain.

3rd PRIORITY

Nursing Diagnosis
Risk for
imbalanced fluid
volume related to
inadequate fluid
intake.

Related drug
therapeutics

Related Lab
diagnostics

Short Term
Goal
After 8 hours of
nursing
intervention:
Patient will
maintain
adequate fluid
intake as
evidenced by
systolic BP
greater than or
equal to 90
mmHg and
normal skin
turgor.

1.

2.

3.
4.
5.

Nursing
Interventions
Monitor and
document VS
especially BP
and HR.
Assess skin
turgor and oral
mucous
membranes for
dehydration/
Urge patient to
drink prescribed
amount of fluid.
Emphasize
importance of
oral hygiene.
Emphasize the
relevance of
maintaining
proper nutrition
and hydration.

Rationale
1.

2.
3.

4.

5.

Decrease in circulating
blood volume can cause
hypotension and
tachycardia.
Poor skin turgor may
indicate dehydration.
Older patient have a
decrease sense of thirst
and may need ongoing
reminders to drink.
Fluid deficit can cause a
dry, sticky mouth.
Attention to mouth care
promotes interest in
drinking an reduces
discomfort of dry
mucous membranes.
Increase the patients
knowledge level will
assist in preventing and
managing the problem.

Evaluation/
Outcome
After 8 hours of
nursing
intervention:
Patient was able
to:
Patient will
maintain
adequate fluid
intake as
evidenced by
systolic BP
greater than or
equal to 90
mmHg and
normal skin
turgor.