ASSESMEN

T
Subjective:
hinihimas
ko un mga
manok na
panabong
ko para
mawala ang
pagod ko
BP
130/80mmH
g
RR 28
PR 72
TEMP
36.3C

DIAGNOSI
S

PLANNING

IMPLEMENTATION

Knowledge
deficient
[Learning
Need]
regarding
condition,
treatment
regimen,
self care,
and
discharge
needs as
evidenced
by clients
fond of cock
fight

After 8
hours of
nursing
intervention
s, patient
will
verbalize
how to
initiate
necessary
lifestyle/
behavioural
changes.

Discuss normal heart function.

Include information regarding
patients variance from normal
function. Explain difference
betweenheart attack and HF.
(Knowledge of disease
process and expectations can
facilitate adherence to
prescribed treatment
regimen.)
Explain and discuss patients
role in control of risk factors
(smoking, unhealthy diet) and
precipitating or aggravating
factors (high-salt diet,
inactivity, overexertion,
exposure to extremes in
temperature).( Adds to body of
knowledge, and permits
patient to make informed
decisions regarding control of
condition and prevention of
complications. Smoking
potentiates vasoconstriction;
sodium intake promotes water
retention or edema formation;
improper balance between
activity and rest and exposure
to temperature extremes may
result in exhaustion and/or
increased myocardial
workload and increased risk of
respiratory infections. Alcohol
can depress cardiac
contractility. Limitation of
alcohol use to social
occasions or maximum of 1
drink per day may be tolerated

EVALUATIO
N
After 8
hours of
nursing
intervention
s, patient
verbalize
how to
initiate
necessary
lifestyle/
behavioural
changes.

unless cardiomyopathy is
alcohol-induced (requiring
complete abstinence).
Discuss general health risks
(such as infection),
recommending avoidance of
crowds and individuals with
respiratory infections,
obtaining yearly influenza
immunization and onetime pneumonia immunization
.
(This population is at
increased risk for
infection because of
circulatory compromise.)
ASSESME
DIAGNOSIS
NT
Subjective
Knowledge
:
deficient
sa
nakalipas
[Learning
na
Need]
dalawang
taon arawregarding
araw ako
condition,
nagbubuki
d buong
treatment
araw

regimen, self

Objective:
Skin
color? Lol
Rough
hands and
feet? Lol

care, and

Vital
signs:

pagkahilig sa

discharge
needs as
evidenced by
clients
pagkain.

PLANNING

IMPLEMENTATION

After 8
hours of
nursing
interventio
ns, patient
will
verbalize
how to
initiate
necessary
lifestyle/
behavioural
changes.

Discuss normal heart

function. Include
information regarding
patients variance from
normal function.
Explain difference
betweenheart
attack and HF.
(Knowledge of disease
process and
expectations can
facilitate adherence to
prescribed treatment
regimen.)

Discuss importance
of being as active as
possible without
becoming exhausted
and of rest between
activities.
(Excessive physical

EVALUATIO
N
After 8
hours of
nursing
interventio
ns, patient
verbalized
how to
initiate
necessary
lifestyle/
behavioural
changes.

activity or
overexertion can
further weaken the
heart, exacerbating
failure, and
necessitates
adjustment of
exercise program.)
Explain and discuss
patients role in
control of risk factors
(smoking, unhealthy
diet) and
precipitating or
aggravating factors
(high-salt diet,
inactivity,
overexertion,
exposure to
extremes in
temperature).
(Adds to body of

knowledge, and
permits patient to
make informed
decisions regarding
control of condition and
prevention of
complications.
Smoking potentiates
vasoconstriction;
sodium intake
promotes water
retention or edema
formation; improper
balance between
activity and rest and
exposure to
temperature extremes
may result in
exhaustion and/or

increased myocardial
workload and
increased risk of
respiratory infections.
Alcohol can depress
cardiac contractility.
Limitation of alcohol
use to social occasions
or maximum of 1 drink
per day may be
tolerated unless
cardiomyopathy is
alcohol-induced
(requiring
complete abstinence).

Identify community
resources and
support groups and
visiting home health
nurse as
indicated. Encourage
participation in an
outpatient cardiac
rehabilitation
program.
(May need additional
assistance with selfmonitoring, home
management,
especially when HF
is progressive.)

ASSESMENT

DIAGNOSIS

PLANNING

Subjective:
Namamaga
ang paa ko as
verbalized by
th patient.

Fluid Volume
Excess related
to sodium
retention as
manifested by
presence of
edema in right

After 8 hours
of nursing
interventions,
patient will
verbalize
understanding
of the

Objective:

IMPLEMENTATI
ON
-establish
rapport
-monitor and
record vital
signs

EVALUATION
After 8 hours of
nursing
interventions,
patient
verbalized
understanding
of measures to

Presence of
edema in right
foot grade 4.

foot.

measures to
prevent and
lessen fluid
volume excess.

Vital signs:
BP
130/80mmHg
RR 28
PR 72
TEMP 36.3C

-compare
current weight
gain with
admission or
previous
stated weight

prevent and
lessen fluid
volume excess.

-discuss the ff
measures to
prevent and
lessen fluid
volume excess.
a) advice
patient foot
when sitting
down. (this is
to prevent and
lessen fluid
accumulation
in right foot)
b)instruct
patient
regarding
restricting fluid
intake.(intake
of fluid up to
500ml is
equivalent to
0.5 kg.
Increase in
weight due to
fluid retention.
Therefore
limiting is
necessary to
avoid fluid
retention)

ASSESMEN
T
Subjective:
mahilig
ako sa
mga
matataban
g pagkaen
lalo na

DIAGNOSIS

Knowledge
deficient
[Learning
Need]
regarding

PLANNING

IMPLEMENTATION

After 8
hours of
nursing
interventio
ns, patient
will
verbalize

- Discuss normal
heart function.
Include information
regarding patients
variance from normal
function. Explain

EVALUATIO
N
After 8
hours of
nursing
interventio
ns, patient
verbalized
understand

sinigang
na my
sawsawan
na patis at
sili as
verbalized
by the
patient.

condition,

Objective:
Weight: ?
Body
Complexio
n:?

evidenced by

Vital
Signs:

treatment
regimen, self
care, and
discharge
needs as
clients
pagkahilig sa
pagkain.

understand
ing of the
measures
to prevent
and lessen
sodium
intake and
fatty foods.

difference
betweenheart
attack and HF.
(Knowledge of
disease process and
expectations can
facilitate adherence
to prescribed
treatment regimen.)
- Discuss importance

of sodium limitation.
Provide list of sodium
content of common
foods that are to be
avoided and limited.
Encourage reading of
labels on food and
drug packages.
(Dietary intake of

sodium of more than

3 grams per day can
offset effect of
diuretic. Most
common source of
sodium is table salt
and obviously salty
foods, although
canned soups,
luncheon meats, and
dairy products also
may contain high
levels of sodium.)
Refer to dietitian for
counseling specific
to individual dietary
customs.
(Identifies dietary
needs, especially in
presence of nausea

ing of the
measures
to prevent
and lessen
sodium
intake and
fatty foods.

vomiting and
resulting wasting
syndrome (cardiac
cachexia). Eating six
small meals and
using liquid dietary
supplements and
vitamin supplements
can limit
inappropriate weight
loss.)
Explain and discuss
patients role in control
of risk factors
(smoking, unhealthy
diet) and precipitating
or aggravating factors
(high-salt diet,
inactivity, overexertion,
exposure to extremes
in temperature).
(Adds to body of

knowledge, and
permits patient to
make informed
decisions regarding
control of condition
and prevention of
complications.
Smoking potentiates
vasoconstriction;
sodium intake
promotes water
retention or edema
formation; improper
balance between
activity and rest and
exposure to
temperature
extremes may result

in exhaustion and/or
increased myocardial
workload and
increased risk of
respiratory
infections. Alcohol
can depress cardiac
contractility.
Limitation of alcohol
use to social
occasions or
maximum of 1 drink
per day may be
tolerated unless
cardiomyopathy is
alcohol-induced
(requiring
complete abstinence
Identify community
resources and
support groups and
visiting home health
nurse as
indicated. Encourage
participation in an
outpatient cardiac
rehabilitation
program.
(May need additional
assistance with selfmonitoring, home
management,
especially when HF is
progressive.)

ASSESMENT

DIAGNOSIS

PLANNING

SUBJECTIVE:
para akong
nahahapo
itong nakalipas

Decreased
cardiac output
related to
altered

After 8 hours
of nursing
intervention
the patient will

IMPLEMENTATI
ON
INDEPENDENT:
Auscultate
apical pulse;
assess heart

EVALUATION
After 8 hours of
nursing
intervention
the patient

na buwan
OBJECTIVE:
Cool, ashen
skin.
Orthopnea
Crackles V/S
taken as
follows T: 36.2
C P: 130 R: 45

myocardial
contractility
/inotropic
changes.

display vital
signs within
acceptable
limits,
dysrhythmias
controlled and
no symptoms
of failure.

rate, and
rhythm.
( Tachycardia
is usually
present even
at rest to
compensate
for decreased
ventricular
contractility.)
Inspect skin
for pallor,
cyanosis.
(Pallor is an
indicative of
diminished
peripheral
perfusion
secondary to
inadequate
cardiac output,
vasoconstrictio
n, and anemia.
Cyanosis may
develop in
refractory
heart failure.
Dependent
areas are often
blue or mottled
as venous
congestion
increases.)
Monitor
urine output,
noting
decreasing
output and
dark or
concentrated
urine. (Urine
output is
usually
decreased
during the day
because of
fluid shifts into
tissues but

was able to
display vital
signs within
acceptable
limits,
dysrhythmias
controlled and
no symptoms
of failure.

may be
increased at
night because
fluid returns to
circulation
when patient is
recumbent.)
Note changes
in sensorium.
(May indicate
inadequate
cerebral
perfusion
secondary to
decreased
cardiac
output.)
Provide quiet
environment.
(Psychological
rest help
reduce
emotional
stress, which
can produce
vasoconstrictio
n, elevating BP
and increasing
heart rate or
work.)
DEPENDENT:
Administer
supplemental
oxygen as
indicated.
(Increases
available
oxygen for
myocardial
uptake to
combat effects
of hypoxia or
ischemia.)
Administer

diuretics as
prescribed.
(Diuretics, in
conjunction
with restriction
of dietary
sodium and
fluids, often
lead to clinical
improvement
in patients
with heart
failure.)