Decrease cardiac output related to altered stroke volume.

ASSESSMENT Objective: Vital Signs: BP: 156/62 mmhg PR: 63 bpm RR: 15 cpm TEMP: 36.5 C O2 Sat: 100% Pallor Capillary refill time: 3 seconds Clammy skin noted GOALS AND OBJECTIVES Short Term After 2 hours of nursing intervention, patientblood pressure will be lowered down from 156/62 to 120/80. Long Term:
After 3 days of nursing intervention, patient will maintain adequate cardiac output and cardiac index.

NURSING INTERVENTIONS AND RATIONALE: Independent: 1. On low-salt, low-fat diet. R: To prevent hypertension.

2. Placed on a moderate high back rest. R: decreases oxygen consumption and risk of decomposition.
3. Stress importance of accomplishing dailyrest periods. R: Alternating restand activityincreasestolerance toactivityprogression. 4. Frequent position changes,leg exercises when lying down. R: Decreases peripheral venous pooling that may be potentiated by vasodilators.

Dependent: 1. Administered Atenolol as ordered by the physician. R: To help reduce blood pressure. 2. Administered Clonidine as ordered by the physician. R: To help reduce blood pressure.

1. Impaired gas exchange related to fluid shift on alveoli secondary to pulmonary edema
Assessment Subjective Cues: Ga lisud ko hinga as verbalized Objective Cues: Use of accessory muscles when breathing Dyspnea Orthopnea Crackles Cyanosis Oxygen saturation: 70-90%

Goals and Objectives: Short-term:

After 15-30 minutes of nursing intervention, the patient will be able to demonstrate improved ventilation and adequate oxygenation of tissues.

Long-term: After 8 hours of nursing interventions, the patielt will have improve respiration.

Nursing Intervention Elevated head of bed/position clients head appropriately, in a semi-Fowler's position as tolerated to allow increased lung expansion because the abdominal contents are not crowding the lungs. Demonstrated and encouraged frequent deep breathing/coughing exercises to promote optimal chest expansion. Demonstrate and encourage the client to use pursed-lip breathing to increased use of intercostal muscles, decreased respiratory rate, increased tidal volume, and improved oxygen saturation levels. Minimize activities andenergy expenditures byassisting ADLs to reduce oxygen and energy demand Evaluation Short-term: After 15-30 minutes of nursing intervention, the patient was able to demonstrate improved ventilation and adequate oxygenation of tissues. Goals met. Long-term: After 8 hours of nursing interventions, the patient has an improved respiration. Goals met.