Nursing Care Plan
1
Lethbridge University, NESA program
Nursing Care Plan
Assessment
Subjective:
Complaining
of SOB,
especially at
night and
when walking,
fatigue, and
swelling in his
ankles and
feet.
Stated, did not
take his “water
pill” for the last
5 days
because his
wife’s ankles
were swollen
so he gave the
pill to her.
Admitted to
being “out of
them heart
pills” but
cannot
remember
which ones.
Nursing
Diagnosis
Activity
intolerance r/t
weakness,
fatigue
Expected outcomes
Interventions
Rationale
Evaluation
Patient will
participate in physical
activity with
appropriate changes
in heart rate, blood
pressure and
breathing rate by the
end of the month.
Allow for periods of rest before
and after planned exertion
periods such as meals, baths,
treatments, and physical
activity.
Patient will have both
emotional and
physical rest which
will help lower arterial
pressure and reduce
workload of the
myocardium
Client will
have
increased
activity
tolerance by
the end of
the month.
Slow the pace of care. Allow
the client extra time to carry out
activities
Patient will improve
the time it takes to do
daily activities.
Refer to heart failure program
or cardiac rehabilitation
program for education,
evaluation, and guided support
to increase activity and rebuild
like.
Patient will improved
exercise capacity and
quality of life in mild
to moderate heart
failure.
Patient will be able to
verbalize an
understanding of the
need to gradually
increase activity
based on teaching
and symptoms by the
end of the week.
Patient will have
reduced number of
cardiac deaths, also
decreasing
cholesterol levels,
and blood pressure.
Client will
verbalize
understandin
g of
gradually
increasing
activity by
the end of
the week.
Nursing Care Plan
States is on
several heart
medications.
Objective:
-69 year old
male. Allergic
to penicillins,
cephalosporin
s, and
midazelam.
Physical exam
revealed mild
respiratory
distress and
2+ dependent
pitting edema.
Serum
creatine level
was 88.4
umol/L
12 lead ECG
revealed sinus
tachycardia
without
ectopy. Chest
radiography
showed
cardiomegaly
Excess fluid
volume r/t
impaired
excretion of
sodium and
water.
2
Patient will remain
free of edema,
effusion,and
anasarca; and
maintain stable
weight by the end of
two weeks.
Monitor location and extent of
edema; use a millimetre tape in
the same area at the same time
each say to measure edema in
extremities.
Patient will maintain
clear lung sounds no
evidence of dyspnea
or orthopnea by the
end of the month.
Monitor lung sounds for
crackles, monitor respirations
for effort, and determine the
presence and severity of
orthopnea.
Patient will maintain
clear air ways and
have adequate
oxygen/carbon
dioxide exchange at
the alveolar-capillary
membrane.
Patient will
maintain
clear lung
sounds by
the end of
the month.
Patient will be able to
explain measures
that can be taken to
treat or prevent
excess fluid volume,
especially fluid and
dietary restrictions
and medications by
Monitor for side effects of
diuretic therapy, orthostatic
hypotension, hypovolemia and
electrolyte imbalances.
Fluid restrictions may
decrease
intravascular volume
and myocardial
workload
Patient will
verbally
explain
different
measures
that can be
taken to
prevent
Monitor daily weights for
sudden increases; use same
scale and type of clothing at
same time each day, preferably
before breakfast to asses
hydration status, and fluid
overload
Patient will have
decrease in edema
and swelling in
extremities
Patient will
remain
stable when
it comes to
their fluid
volume by
Patient will maintain a the end of
stable weight.
two weeks.
Nursing Care Plan
with lung
filtrates.
ABG results
are pending.
Swelling in
ankles and
feet.
the end of the week.
Implement fluid restriction as
ordered , especially when
serum sodium is low; include all
routes of intake.
A cognitivebehavioural group
effectively helps
Calculate an appropriate daily
clients adhere to fluid
fluid intake amount and work
restrictions.
with client to establish a fluid
intake goal.
3
excess fluid
volume.
Provide scheduled rest periods. Bed rest can induce
diuresis related to
diminished peripheral
venous pooling,
resulting in
intravascular volume
and glomerular
filtration rate.
Care plan to
be
reassessed
in 3 months
with health
care team