V.

NURSING CARE PLAN

1ST PRIORITY

Nursing Diagnosis Related drug Related Lab Short Term Nursing Rationale Evaluation/
therapeutics diagnostics Goal Interventions Outcome
Ineffective cardiac Captopril Chest x-ray After 8 hours of 1. Asses for 1. Provides baseline After 8 hours of
tissue perfusion Trimetazidine Electrocardiogr nursing signs of for future nursing
related to reduced Isosorbide am intervention: decreased comparison. intervention:
Mononitrate Arterial Blood tissue 2. Ischemic pain may
coronary blood
Clopidrogrel Gases Patient will be perfusion. result in respiratory Patient was able
flow. Capillary refill able to exhibit 2. Check for distress. to:
no further respiration 3. Low levels reduce
worsening/repet and absence the uptake of To exhibit no
ition of deficits of work or oxygen at the further
and maintain breathing. alveolar-capillary worsening/repetit
maximum 3. Check membrane and ion of deficits
tissue perfusion Hemoglobin oxygen delivery to and maintain
to vital organs levels and tissues. maximum tissue
as evidenced by pallor, 4. To prevent venous perfusion to vital
warm and dry quality of stasis and further organs as
skin, present pulse. circulatory evidenced by
and vitals 4. Promote compromise. warm and dry
within patients active/passiv 5. To facilitate skin, present and
normal range, e ROM perfusion by vitals within
normal ABGs exercises reducing blood patients normal
and absence of 5. Administer viscosity and range, normal
chest pain. medications coagulation and to ABGs and
as prescribed reduce systemic absence of chest
such as vascular resistance pain.
antiplatelet and optimize cardiac
and anti- output and
hypertensive perfusion.
s.
2ND PRIORITY
Nursing Diagnosis Related drug Related Lab Short Term Nursing Rationale Evaluation/
therapeutics diagnostics Goal Interventions Outcome
Decrease cardiac Captopril Chest x-ray After 8 hours 1. Assess the patient 1. Assessment is required After 8 hours of
output related to Trimetazidine Electro- of nursing on the following: in order to possible nursing
alteration heart rate, Isosorbide cardiogram intervention: a. Skin color problems that may lead intervention:
Mononitrate b. Alteration in to worsening of
rhythm and
Patient will be LOC condition. Pale skin is Patient was able
conduction. able to c. Heart rate and secondary to compensate to:
demonstrate Blood low cardiac output.
adequate pressure Restlessness and Demonstrate
cardiac output 1. Administer irritability reflected adequate
as evidenced cardiac decreased cerebral cardiac output
by blood medications such perfusion. Tachycardia as evidenced
pressure and as ACE inhibitors. and low BP is a response by blood
pulse rate 2. Record intake and to compensate reduced pressure and
within normal output cardiac output. pulse rate
parameters 3. Position patient 2. Assess patients within normal
and ability to in semi to high tolerance before giving parameters and
tolerate fowlers medication. ability to
activity 4. Administer 3. Reduced cardiac output tolerate activity
without oxygen as results in reduced without
dyspnea or prescribed. perfusion of the kidneys. dyspnea or
chest pain. 4. To reduce preload and chest pain.
ventricular filling when
fluid overload is the
cause.
5. Failing heart may not be
able to respond to
increased oxygen
demands.
3rd PRIORITY
Nursing Diagnosis Related drug Related Lab Short Term Nursing Rationale Evaluation/
therapeutics diagnostics Goal Interventions Outcome
Risk for After 8 hours of 1. Monitor and 1. Decrease in circulating After 8 hours of
imbalanced fluid nursing document VS blood volume can cause nursing
volume related to intervention: especially BP hypotension and intervention:
inadequate fluid and HR. tachycardia.
intake. Patient will 2. Assess skin 2. Poor skin turgor may Patient was able
maintain turgor and oral indicate dehydration. to:
adequate fluid mucous 3. Older patient have a
intake as membranes for decrease sense of thirst Patient will
evidenced by dehydration/ and may need ongoing maintain
systolic BP 3. Urge patient to reminders to drink. adequate fluid
greater than or drink prescribed 4. Fluid deficit can cause a intake as
equal to 90 amount of fluid. dry, sticky mouth. evidenced by
mmHg and 4. Emphasize Attention to mouth care systolic BP
normal skin importance of promotes interest in greater than or
turgor. oral hygiene. drinking an reduces equal to 90
5. Emphasize the discomfort of dry mmHg and
relevance of mucous membranes. normal skin
maintaining 5. Increase the patients turgor.
proper nutrition knowledge level will
and hydration. assist in preventing and
managing the problem.