NURSING CAREPLAN FORM
Date _____________
Nursing
Diagnosis
Desired patient
outcome
Nursing
intervention
s
Rationale
Evaluation
of desired
patient
outcome
Standard:
Decreased
Cardiac Output
(SMART) Specific,
Measureable,
Attainable,
Realistic, Timed
Assess,
Diagnostic,
Actions/
Treatments,
Meds,
Teaching,
Geriatric (or
developmental).
Other Patient
Specific
Interventions
Explains why.
Relates to the
problem and
desired outcome
R/T (related to)
Altered heart
rhythm, altered
preload, altered
afterload,
altered
contractility,
behavioral/emo
tional changes
Short term goal:
Patient will remain
free of side effects
from medication
used to improve
cardiac output.
Indicates if
DPO met,
partially met,
or not met and
criteria used
to determine
this. Focus on
patient
response
rather than
nurse action
Short term
goal: Met
partially.
Patient had no
complaints of
furthering
symptoms
from
medication
(Lasix) such
as dizziness,
drowsiness, or
drop in blood
pressure.
Patient did
have lowered
potassium
levels with no
symptoms.
Long term goal:
Patient will
maintain adequate
cardiac output as
evidence by blood
pressure, pulse
rate, and rhythm
within controlled
parameters.
Long term
AEB (as
evidenced by)
abnormal heart
rhythm with
defibrillator,
jugular vein
distention,
edema in lower
extremities,
weakened
extremity
pulses, dyspnea
upon activity,
increase in
restlessness
Assessments:
Assess patient’s
vital signs,
especially heart
rate and blood
pressure
goal: unable
to assess due
to time
constraints.
Patients blood
pressure,
pulse rate is
stable
currently.
Tachycardia,
0654 vitalsdecreased
97.3 temp,
oxygen
pulse 64,
saturation, and
respirations
hypotension are 18, O2 sat
typical signs of 100%, B/P
decreased
150/68.
cardiac output.
1007 vitalsCardiomegaly is 97.6 temp,
a condition that pulse 68,
results from
respirations
chronic
18, O2 sat
hypertension
97%, B/P
which reduces
148/67.
cardiac output
because of
Vital signs
reduction in
show
amount of blood increased B/P
the heart
which patient
pumps.
has chronic
hypertension.
Patient is on 2
L of oxygen
via nasal
cannula.
Assess patient’s
skin
Assess
peripheral
pulses, pulse
deficits,
capillary refill
Assess patient
for edema
Changes in skin
color, moisture,
and temperature
show signs of
SNS
involvement in
decreased
cardiac output
and decreased
oxygenation.
Skin is cold,
clammy,
diaphoretic,
pale, cyanotic,
edematous.
Decreased
cardiac output
causes
weakened
peripheral
pulses and
sluggish or
nonexistent
capillary refills.
Pulse deficits
occur when
there is a
decreased
cardiac output
because of poor
peripheral
perfusion.
In compromised
cardiac system,
Patient is of
African
descent, so
membranes
were assessed.
They are rosy
pink and
moist. Skin is
dry and warm.
No pulse
deficits
detected.
Capillary refill
less than 3
seconds.
Weakened
lower
extremity
pulses due to
lower
peripheral
edema (1+).
Generalized
lower edema
Assess for
Jugular neck
vein distention
Assess mental
status or level
of
consciousness
Assess breath
sounds and
breathing
patterns
fluid retention is
common
because of the
hearts inability
to pump
efficiently.
Fluid is backed
up from the
right side of the
heart causing
elevated
pressures in
jugular veins.
This is most
often found in
HF, right
ventricular MI,
COPD, Heart
Block,
arrythmias or
fluid volume
overload.
Changes are
from decreased
oxygen
reaching the
brain because of
decreased blood
flow.
Shallow, rapid
respirations and
crackles are all
common in left
sided heart
failure.
non pitting.
Jugular vein
distention
noted on both
sides of
patient’s neck.
Patient is alert
and oriented x
4.
Patient upon
admission was
extremely
SOA, bilateral
crackles.
Patient now
has clear lung
fields, use of
accessory
Assess patient’s
Input and
output
Labs/Diagnostic
Studies
Assess patient’s
electrolyte
levels
Evaluate
cardiac
enzymes
Decreased
output is a sign
of decreased
cardiac output
because of
profusion issues
to organs
(kidneys)
Often treatment
increases output
which depletes
electrolytes by
urination.
Cardiac
Enzymes are
deposited in the
blood stream
when damage
has occurred in
the cardiac
muscle.
muscles upon
exertion as
well as c/o
SOA upon
exertion.
Patient has
taken self to
restroom
without
monitoring.
Patient’s
levels of
potassium
have
decreased due
to Lasix
treatment.
Potassium
level is 3.4.
Potassium
protocol
ordered and
patient was
given 20 meq
of potassium.
Lab to
recheck.
Troponin
levels were
within normal
limits.
Evaluate BNP
and Creatine
Actions/Treatments Decrease
oxygen needs
of the body
Follow a
cardiac diet
Troponin levels
are the best way
to effectively
evaluate if
damage is or
has occurred.
BNP elevation
without CREA
elevation is a
sign of HF.
Creatinine
levels elevated
at 1.71. ProBNP
extremely
elevated at
34202. This
should be no
greater than
450 in adults
75-99.
Oxygen
Patient I on
supplementation 2Liters of
may decrease
oxygen via
the body’s
nasal canula.
compensatory
mechanisms
(increased HR,
RR, B/P) and
rest or reduced
activity to
decrease the
body’s
demands.
Diet healthy for Patient is
the
ordered a
cardiovascular
cardiac diet.
system which is Patient states
low in fats, high they eat the
in fiber, low in
right foods but
salt
will not
elaborate.
Medications
Administer
diuretics
Patient teaching
Educate patient
on importance
of daily weights
Geriatric
considerations
Assess for
abnormal signs
of decreased
cardiac output
and HF
Assess side
effects of
cardiac meds
Diuretics reduce
excess fluid in
vascular and
tissue systems.
This reduces the
workload of the
heart and
decreases the
body’s
demands.
Daily weights
can help
monitor fluid
retention which
can exacerbate
CHF symptoms
Fatigue and
depression are
often sign of
decreased
cardiac output
and HF because
of the body’s
inability to
adapt to
demands
Metabolism in
the elderly is
slow due to
decreased
kidney and liver
function and are
more likely to
experience toxic
side effects
Patient
received 40mg
Lasix IV push
once daily.
Patient stated
understanding
of education.
Patient has
noted daytime
fatigue and
fatigue with
activity
Patient
creatinine
level is
elevated at
1.71. This
could be
related to
treatment of
CHF
exacerbation
with Lasix.
Creatinine
levels
signifies
impaired
kidney
function.
Potassium
levels
decreased to
3.4. Potassium
protocol
ordered and
20 meq of
potassium
given.
Nursing
Diagnosis
Desired patient
outcome
Nursing
intervention
s
Rationale
Evaluation
of desired
patient
outcome
Standard:
Activity
intolerance
(SMART) Specific,
Measurable,
Attainable,
Realistic, Timed
Assess,
Diagnostic,
Actions/
Treatments,
Meds,
Teaching,
Geriatric (or
developmental).
Other Patient
Specific
Interventions
Explains why.
Relates to the
problem and
desired outcome
Related to:
Decreased
Cardiac output,
decreased
oxygen supply,
sedentary
lifestyle,
compromised
oxygen
Short Term Goal:
Patient will
maintain normal
skin conditioning
such as being
warm, pink, and
dry.
Long Term Goal:
Patient will
Indicates if
DPO met,
partially met,
or not met and
criteria used
to determine
this. Focus on
patient
response
rather than
nurse action
Short Term
Goal: Met.
Patients
mucus
membranes
stayed rosy
pink, warm
and dry.
Long Term
transport
demonstrate
increased tolerance
to activity by not
showing signs of
labored breathing
with little activity.
Goal: Unable
to assess due
to time
restraint.
Patient had
labored
breathing at
sat dropping
when moving
around in
room.
As Evidence
By: Congestive
heart failure,
oxygen usage,
labored
breathing and
O2 stat
dropping upon
activity
Assessment
Assess vital
signs
Assessing
patient’s vital
signs especially
at rest makes it
easier to
compare vital
signs with and
without activity.
0654 vitals97.3 temp,
pulse 64,
respirations
18, O2 sat
100%, B/P
150/68.
1007 vitals97.6 temp,
pulse 68,
respirations
18, O2 sat
97%, B/P
148/67.
Patient is on
oxygen at 2 L.
Patients
baseline
Assess for
generalized
weakness
Assess
circulatory
condition
Assess
respiratory
status
reading of
100%
oxygenation
dropped to
97% when
making their
bed.
Weakness
Patient’s foot
hinders a
pushes and
patient’s ability handgrips
to perform tasks strong and
efficiently and
even. Fair
the body’s
Range of
ability to
motion.
function
Patient has
properly under
proper gait
the demand of
without use of
oxygen and
assistive
blood
devices.
There is an
Patient was
imbalance
diagnosed
between oxygen with CHF and
supply and
has been
demand. The
hospitalized
heart cannot
for
efficiently
exacerbations.
pump enough
Lower
oxygenated
extremity
blood to support peripheral
tissues.
pulses weak,
capillary refill
within normal
limits. Jugular
vein distention
noted.
Left sided heart Patient has
failure causes
jugular vein
blood to back
distention
up into the
lungs causing
problems
breathing.
Assess for
exertional
dyspnea
Lab/ diagnostic
studies
Dyspnea or
SOA is
identified as
difficult or
labored
breathing.
Monitor oxygen Monitoring
saturations
oxygenation
which is
common in
right sided
heart failure.
When right
sided heart
failure is
present,
usually the
left side is
affected also.
Patient has
diagnosis of
CHF. With
treatment lung
fields sound
clear. Patient
is receiving 2
Liters of
oxygen via
nasal canula.
Patient had
difficulty
talking at
faster speeds
because of
SOA. Patient
had SOA
symptoms like
labored
breathing after
activity
(making own
bed and
walking
around room)
Patient on 2L
of oxygen via
Evaluate CBC,
BNP,
Creatinine,
electrolytes and
BUN/CRE
status will
ensure quick
intervention if
oxygen
demands are not
met.
Lab work may
indicate reason
behind
symptoms that
cause activity
intolerance such
as possible
anemia, cardiac
insufficiencies,
respiratory
insufficiencies,
nutritional
insufficiencies.
nasal canula.
Continuous
tele and pulse
ox. Saturation
staying at
97% or above.
Patient
creatinine
level is
elevated at
1.71. This
could be
related to
treatment of
CHF
exacerbation
with Lasix.
Creatinine
levels
signifies
impaired
kidney
function.
Potassium
levels
decreased to
3.4. Potassium
protocol
ordered and
20 meq of
potassium
given.
Troponin
levels were
within normal
limits.
Creatinine
levels elevated
at 1.71. Pro-
Actions/TX
Provide oxygen
therapy
Employ energy
saving
strategies
Medications
Administer
Oxygen therapy
allows the
respiratory and
cardiovascular
system to not
work as hard for
appropriate
oxygenation
Energy saving
strategies
include pacing
and frequent
resting during
activities. This
allows patient to
not exert self
too much at any
given time
during activity
Diuretics reduce
BNP
extremely
elevated at
34202. This
should be no
greater than
450 in adults
75-99. HCT
32.1 (low),
RBC 3.64
(low), HGB
10.1 (low)
which all
indicate
anemia. This
can lead to
oxygenation
issues.
Patient is on
oxygen
therapy 2
liters via nasal
canula
Encouraged
patient to take
rest during
activity and
allow for
relaxation to
decrease
oxygen
demands of
the body.
Patient
diuretics
Nursing
Diagnosis
Standard:
Risk for
impaired skin
integrity
excess fluid in
vascular and
tissue systems.
This reduces the
workload of the
heart and
decreases the
body’s
demands.
Resting or
pacing activity
increases
tolerance for
activity.
received 40mg
Lasix IV push
once daily.
Teaching
Teach patient
the importance
of mixing
activity with
periods of rest.
Patient stated
understanding.
Encouraged
them to take
their time
when moving
in the room
and talking.
Patient is at
medium fall
risk due to
recent fall at
home, IV
apparatus and
weakened
state.
Geriatric
implications
Assess fall risk
Poor balance,
weakened
muscle tone,
fear of falling
all affect
motility, effort
and tolerance
Desired patient
outcome
Nursing
intervention
s
Rationale
Evaluation
of desired
patient
outcome
(SMART) Specific,
Measurable,
Attainable,
Realistic, Timed
Assess,
Diagnostic,
Actions/
Treatments,
Meds,
Teaching,
Geriatric (or
developmental).
Other Patient
Explains why.
Relates to the
problem and
desired outcome
Indicates if
DPO met,
partially met,
or not met and
criteria used
to determine
this. Focus on
patient
response
Specific
Interventions
Related To:
advanced age,
physical
limitations,
alteration in
skin turgor,
xerosis,
impaired
circulation
Short term goal:
Patient’s skin will
remain intact
throughout shift.
Long Term goal:
Patient’s edema
will subside and
return to normal
baseline.
As evidence
Assessment
by: age,
activity
intolerance, dry
skin, edema,
CHF
exacerbation
Assess overall
skin condition
Assess Braden
scale
rather than
nurse action
Short term
goal: Met.
Patient
remained free
of skin
openings,
redness.
Long term
goal: Unable
to assess due
to time
constraints.
Patient still
has non
pitting edema
in lower
extremities
and slightly
pitting edema
in left arm.
Assessing the
Patient skin is
patient’s overall dry and flaky.
skin condition
Edema present
can identify
in lower
weakened and
extremities
problemed areas (non-pitting)
that may need
and in left arm
attention
(slightly
pitting).
Patients skin
is warm and
normal for
race.
Braden scale is Patient was at
a quick and
medium risk
easy assessment of skin
tool used to
identify patients
at risk for skin
integrity issues.
breakdown
due to chronic
illnesses, age,
and skin
condition at
the time.
Assess edema
Skin that is
Edema present
taught or
in lower
edematous is at extremities
greater risk for
(non-pitting)
imparities
and in left arm
(slightly
pitting).
Assess for skin Irritations may
Patient skin is
irritations
result is itching extremely dry
or blisters that
and flaky.
potentially can
Patient has no
lead to skin
complaints of
breakdown/ope pruritis.
ning
Moisture
cream applied.
Assess moisture Moisture
Patient skin is
contributes to
dry. Room
maceration
environment
which can lead
is not
to quickened
humidified
skin breakdown. and cool.
Patient is
continent of
bowel and
bladder.
Assess patient’s Sensing
Patients
ability to feel
pressure or pain ability to feel
pain or pressure gives patients
pain or
the sensation to pressure is
move to
intact.
alleviate
symptoms.
Assess patient’s
mobility status
Labs/Diagnostic
Studies
Evaluate CBC
Actions/Treatments Encourage
ambulation
Keep
edematous
extremities
elevated.
Treat or prevent
Immobility may
cause the
patient inability
to shift, turn or
move off
pressure areas
resulting in skin
breakdown.
Patient can
ambulate on
own. Patient is
at a weakened
state and has
activity
intolerance
but can shift
off pressure
areas.
Anemia can
HCT 32.1
lead to
(low), RBC
decreased
3.64 (low),
oxygenation of
HGB 10.1
the tissues
(low) which
therefore
all indicate
potentially
anemia. This
increasing
can lead to
healing time
tissue
and decreasing
oxygenation
function.
issues.
Ambulation
Encourage
increases
patient to
circulation to
move but to
tissue and
do so at a
prevent pressure paced rate.
breakdown
Elevation helps Encourage
reduce edema
patient to keep
by promoting
left arm
absorption of
elevated with
fluid and
pillow and
promoting
place lower
blood flow back extremities on
toward the
ottoman for
heart.
elevation
when sitting.
Dry skin may
Applied
dry skin
Medications
Use diuretics
when
appropriate to
treat fluid
retention
Teaching
Keep
edematous
extremities
elevated.
Geriatric
Implications
Assess patients
sense of
pressure and
pain
Use lotion and
moisturizers to
prevent dry
skin.
Assess patients
cause pruritis
moisturizer
and lead to open cream to dry
in skin barrier.
flaky skin
areas on legs
and arms to
prevent
cracking and
soothe itching.
Fluid retention
Patient is
leads to
taking 40 mg
edematous areas Lasix IV push
that can cause
daily to
skin integrity
reduce fluid
issues.
retention.
Elevation helps Educated
reduce edema
patient to keep
by promoting
left arm
absorption of
elevated with
fluid and
pillow and
promoting
place lower
blood flow back extremities on
toward the
ottoman for
heart.
elevation
when sitting.
Patient stated
understanding.
Aging causes
Patients
change in
ability to feel
sensation that
pain or
are felt and
pressure is
recognized.
intact.
Dry skin can
Moisturizer
lead to a break
was applied to
in skin barrier.
dry skin areas
on legs and
arms of
patient.
Advanced age
Patient is in
age
4/2016
leads to normal late seventies.
changes in skins
elasticity and
ability to
regenerate.