ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Decreased cardiac output Short Term: Independent: Goal Met

related to congenital heart Assess heart rate and Most patients have
(+) Altered heart defect as evidenced by After 3 hours of doing blood pressure. compensatory tachycardia Short Term:
rate/rhythm: Arrhythmia heart murmur nursing interventions the and significantly low blood
patient will be able to: pressure in response to After 3 hours of doing
(+) Altered preload: Heart (1) Display hemodynamic reduced cardiac output. nursing interventions the
murmur stability patient was able to:
(2) Decreased episodes of Check for peripheral Weak pulses are present in (1) Display hemodynamic
(+) Altered afterload: dyspnea and arrhythmias pulses, including capillary reduced stroke volume and stability
Dyspnea, Abnormal skin refill. cardiac output. Capillary (2) Decreased episodes of
color (cyanosis) refill is sometimes slow or dyspnea and arrhythmias
Long Term: absent.
(+) Behavioral / Emotional: Assess heart sounds for S3 indicates reduced left
Irritability, Prolonged After 2 days of doing gallops (S3, S4). ventricular ejection and is a Long Term:
Crying nursing interventions the class sign of left ventricular
patient and its support failure. S4 occurs with After 2 days of doing
system will verbalize reduced compliance of the nursing interventions the
knowledge of the disease left ventricle, which patient and its support
process, individual risk impairs diastolic filling. system verbalized
factors, and treatment plan Monitor electrocardiogram Cardiac dysrhythmias may knowledge of the disease
(ECG) for rate, rhythm, and occur from low perfusion, process, individual risk
ectopy. acidosis, or hypoxia. factors, and treatment plan
Tachycardia, bradycardia,
and ectopic beats can
further compromise
cardiac output. Older
patients are especially
sensitive to the loss of
atrial kick in atrial
fibrillation.
Position child in semi- Upright position is
Fowler’s position.. recommended to reduce
preload and ventricular
 filling when fluid overload
is the cause; Facilitates
lung expansion
Dependent:

Administer oxygen therapy The failing heart may not

as prescribed. be able to respond to
increased oxygen
demands. Oxygen
saturation need to be
greater than 90%.
Administer medications as
prescribed:

- Digoxin (Lanoxin)
Increases contractility of
the heart and force of
contraction.
- Alprostadil (Prostin VR
Pediatric) Maintain open PDA when
needed for blood flow.

- Furosemide (Lasix); Decreases edema

spironolactone (Aldactone) formation and diminish
afterload.
Collaborative:

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective: Activity intolerance related Short Term: Independent: Goal Met
 to imbalance between Assess heart rate and Most patients have
(+) Exertional discomfort; oxygen supply and demand After 2 hours of doing blood pressure. compensatory tachycardia Short Term:
dyspnea as evidenced by shortness nursing interventions the and significantly low blood
of breath and rapid patient will be able to pressure in response to After 2 hours of doing
(+) Abnormal heart rate breathing especially during demonstrate a decrease in reduced cardiac output. nursing interventions the
response to activity ECG feeding physiologic signs of patient was able to
change (arrhythmia) intolerance Check for peripheral Weak pulses are present in demonstrate a decrease in
pulses, including capillary reduced stroke volume and physiologic signs of
refill. cardiac output. Capillary intolerance
Long Term: refill is sometimes slow or
absent.
After a week of doing Assess heart sounds for S3 indicates reduced left Long Term:
nursing interventions the gallops (S3, S4). ventricular ejection and is a
patient and its support class sign of left ventricular After a week of doing
system will be able to failure. S4 occurs with nursing interventions the
report measurable increase reduced compliance of the patient and its support
in activity tolerance left ventricle, which system were able to
impairs diastolic filling. report measurable increase
Monitor electrocardiogram Cardiac dysrhythmias may in activity tolerance
(ECG) for rate, rhythm, and occur from low perfusion,
ectopy. acidosis, or hypoxia.
Tachycardia, bradycardia,
and ectopic beats can
further compromise
cardiac output. Older
patients are especially
sensitive to the loss of
atrial kick in atrial
fibrillation.
Position child in semi- Upright position is
Fowler’s position.. recommended to reduce
preload and ventricular
filling when fluid overload
is the cause; Facilitates
 lung expansion
Dependent:

Administer oxygen therapy The failing heart may not

as prescribed. be able to respond to
increased oxygen
demands. Oxygen
saturation need to be
greater than 90%.
Administer medications as
prescribed:

- Digoxin (Lanoxin)
Increases contractility of
the heart and force of
contraction.
- Alprostadil (Prostin VR
Pediatric) Maintain open PDA when
needed for blood flow.

- Furosemide (Lasix); Decreases edema

spironolactone (Aldactone) formation and diminish
afterload.
Collaborative: