Você está na página 1de 8


Subjective data:
• ´´I experience pain while passing urine, headaches, headaches, I do not see well, and even
after doing something small, I become very tired easily and for the first time I have
experienced nose bleeding. So I do not understand what is happening to me these days´´
verbalised Mr Neck.

Objective data:
• Decreased cardiac output
• Decreased stroke volume
• Increased peripheral vascular resistance
• Vitals taken as follows:
-Temperature: 37.2 °C
-Pulse rate: 83beats/minutes
-Respiration rate: 18breaths/minutes
-Blood pressure: 180/100mmHg

Nursing diagnosis:
Knowledge deficit related to the underlying heart disease, its consequences and treatment regimen
evidenced by verbalisation of patient.

Goal Nursing intervention Rationale Evaluation

-Patient will -Assess knowledge of -Assessment -After 2 days of the
demonstrate hypertension, establishes baseline nursing intervention,
understanding of underlying disease data from which to the patient was able to
underlying disease process, and build or determine need demonstrate an
process and identify expectations of disease to alter misconceptions.understanding of the
own risk factors or progression. underlying disease
precipitating conditions process and was able to
that require -Encourage -It promotes the patient identify own risk
modification within 2 verbalisation of patient and family engagement factors or precipitating
days of nursing and family concerns in the nursing care. conditions that require
interventions. and their learning modification.

-Assess readiness to -Readiness facilitates

learn. more effective learning.

-Implement teaching -Patient and family

plan, which should have a right to receive
include: information about the
• Explanation of disease, treatment, and
normal heart, prognosis:
heart failure, understanding enhances
and underlying compliance; knowledge
disease process. allays anxieties and the
• Explanation of adverse effects
signs and associated with
symptoms and psychological stress.
risk factors and
factors which
will aggravate
the symptoms
of heart failure
and methods to
modify them.
• Explanation of
(names, dosage,
action and
possible side
• Explanation of
modification if

-Assist patient/family - This helps to enhance

in identifying family self confidence.
strengths and

-Make the patient a -This will help equip

handout to read in the patient with more
simple language about knowledge and enable
the disease which may them make appropriate
incorporate weight decisions about life
control, dietary habits style changes and
and medication compliance to

Nursing diagnosis
Anxiety, related to potential for lifestyle modification, intensive care setting and diagnosis made
evidenced by patient verbalising feelings of fears.

Goal Nursing intervention Rationale Evaluation

Patient will verbalize -Obtain baseline -Baseline data are After 24 hours, the
feelings of less assessment of anxiety essential in evaluating patient was able to
anxiousness and fears level and coping the effectiveness of verbalize feelings of
within 24 hours of patterns from patient, therapeutic less anxiousness and
nursing intervention. family members, or interventions and the fears.
significant others. patients ability to cope.

-Assess level of -Assists in determining

anxiety; include heart the underlying cause of
rate, blood pressure, anxiety and provides a
increased muscle basis f or intervention.
tension, change in
sleeping patterns,
irritability. -Positive feedback
helps nurture
-Determine what the confidence.
individual´s needs are
and what resources can
be mobilized to
decrease feelings of
anxiety; provide
positive reinforcement
when appropriate.
-Helps to create a
-Implement therapeutic trusting relationship;
measures to decrease reassures patient that he
anxiety. is not alone.
• Encourage the
to verbalize -Knowing what to
anxieties and expect will help reduce
concerns; anxiety.
encourage them
to ask
• Explain
procedures and -Will decrease anxiety
limitations to by re-establishing sense
patient and of control and purpose.
• Familiarize
patient with
ICU staff,
routines, and
• Involve patients
in their own
care within
Nursing diagnosis
Non-compliance with the plan of therapy related to knowledge deficit, failure to follow a prescribed
regimen, inadequate support system, or lack of involvement in the treatment plan
evidenced by the patient verbalizing about forgetting medication time.
Goal Nursing intervention Rationale Evaluation
Patient demonstrate a - Assess patients -Inaccurate perception -After the first one
understanding, perception of his illness held by the patient week of nursing care,
acceptance, and and treatment. about the disease and the patient had an
implementation of the its treatment must be understanding,
prescribed treatment identified and corrected acceptance, and
regimen within the first because implementation of the
week of nursing care. misconceptions about prescribed treatment
the disease can easily regimen.
affect compliance.

-Assess patient´s self

care performance
a) Determine baseline
compliance regarding
medications, diet,
weight, exercise, stress
management, smoking
and alcohol.
b) Monitor and record
improvement in

Encourage the patient Fears and frustrations

to express fears or about prescribed
frustrations he has treatment can interfere
related to his health with compliance.

-Encourage active -Patient is likely to take

participation by the an active role in his
patient and the family care if he believes that
for example monitor he has control over
their blood pressure treatment outcomes.
from home if he has the
blood pressure

-Provide continual -This enhances

feedback and compliances and
reinforcement of satisfaction.
adherence behaviour.

-Explain the regimen to -Enhances compliance

the patient, its benefits and satisfaction.
and some of the
problems he will

Nursing diagnosis
Decreased Cardiac Output related to malignant hypertension as evidenced by decreased stroke
Goal Nursing intervention Rationale Evaluation
Short term goal 1. Monitor BP every 1.To monitor Short term goal
After 6 hours of 1-2 hours, or every baseline data. After 8 hours of
nursing 5 minutes during nursing
interventions, the active titration of interventions, blood
client will have no vasoactive drugs. pressure maintained
elevation in blood within set
pressure above parameters for the
2. Monitor ECG for 2. Caffeine is a
normal limits and client.
dysrrhythmias, cardiac stimulant
will maintain blood Goal was met.
conduction defects and may adversely
pressure within and for heart rate. affect cardiac Long term goal
acceptable limits.
function. After 6 days of
Long term goal nursing
After 5 days of 3. Suggest frequent 3. These drugs have interventions, the
nursing position changes. rapid action and client had an
interventions, the may decrease the adequate tissue
client will maintain blood pressure too perfusion to his
adequate cardiac rapidly, resulting in body systems.
output and cardiac complications. Goal was met.
4. Encourage patient 4. May indicate
to decrease intake of cyanide toxicity
caffeine, cola and from increasing
chocolates. intracranial

5. Observe skin 5. Input and Output

colour, temperature, will give an
capillary refill time indication of fluid
and diaphoresis. balance or
imbalance, thus
allowing for
changes in
treatment regimen
6.Monitor for when required.
sudden onset of 6. May indicate
chest pain. dissecting aortic

7. Monitor ECG for

changes in rate, 7. Decreased
rhythm, perfusion may result
dysrhythmias and in dysrhythmias
conduction defects. caused by decrease
8. Observe in oxygen.
extremities for 8.Bed rest promotes
swelling, erythema, venous statis which
tenderness and pain. can increase the risk
Observe for of thromboembolus
decreased peripheral formation. If
pulses, pallor, treatment is too
coldness and rapid and aggressive
cyanosis. in decreasing the
blood pressure,
tissue perfusion will
be impaired and
ischaemia can result.

9. Instruct client in
signs/symptoms to 9. Promotes
report to physician knowledge and
such as headache compliance with
upon rising, treatment. Promotes
increased blood prompt detection
pressure, chest pain, and facilitates
shortness of breath, prompt intervention.
increased heart rate,
visual changes,
oedema, muscle
cramps and nausea
and vomiting.

Nursing Goal Intervention Rationale Evaluation

Activity The patient will be Monitor the This helps in The patient was
intolerance related able to tolerate patients vital signs getting the base able to tolerate
to the disease easy exercises and especially the information of exercises by the
process evidenced will be able to blood pressure how the patient is time they left the
by the patient know what every two hours. performing. hospital.
verbalizing that exercises they able
they get tired to do by the time Teach the patient So that they stop
easily when they leave the relatively easy over straining
performing hospital exercises like their heart with
relatively easy stretching, heavy exercises.
tasks for example walking.
weeding the
flower garden. Refer the patient So that they give
to a them more
physiotherapist so assistance with the
that they can exercises.
continue to teach
the patient on
what exercises
they are able to do
with out over
stressing the heart.

Administer These drugs

medications that reduce the work
reduce the the load of the heart.
hypertension as
prescribed by a
medical doctor.

Reassure the This reduces the

patient that they anxiety of the
would improve. patient so reduces
the stress.
Risk of altered The patient will Monitor the vital This provides base The patient did not
tissue perfusion. not develop tissue signs of the line information develop oedema
oedema during patient. for the nurse, thus from altered tissue
there stay in improves care perfusion.
hospital. given to the

Monitor patient To avoid fluid

fluid intake and overload that
out put by would precipitate
charting the input tissue perfusion or
and output oedema.

High salt diet

Monitor the increase tissue
patient's diet perfusion as water
especially salt follows salt.
intake which
should be low.
Diuretics like
Administer frusemide reduce
medications for tissue perfusion or
example diuretics oedema.
like frusemide as
prescribed by the
medical doctor.
To monitor if the
Weigh the patient patient weight is
twice a day in the relatively constant
morning and and is not
evening. increasing because
of oedema.
Altered health The patient's basic Give the patient a Acts as a massage The patient´s basic
maintenance needs will be bed bath in the and allows blood needs were taken
related to the taken of daily morning and flow and reduces care of during
disease process during there stay evening. bed sores. their stay in
evidenced by the in the hospital. hospital.
patient verbalizing Change the This reduces bed
“I can not do patients bed sheets sores.
things like going and give them
to the toilet, clean ones.
bathing by my


KOZIER B., ERB G., BERMAN A., LAKE R., 2008. Fundamentals of Nursing: concepts, process
and practise. Pearson Education Limited.

SANDRA L. UNDERHILL et al, 2007. Cardiac Nursing. 2nd ed p. 841-842. J.B Lippincott