Republic of the Philippines

NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED
COLLEGE OF NURSING
NURSING CARE PLAN

CARDIOMYOPATHY

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
SUBJECTIVE DATA: Decreased cardiac Short Term: Independent: . Short Term:
“Bigla nalang akong output related to At the end of 3 hours After 3 hours of
nahilo habang altered myocardial of effective nursing - Position patient - Upright position effective nursing
naglalakad” as contractility as intervention, the client in semi- is recommended intervention the client
verbalized by the evidence by changes in will be able to: Fowler’s to to reduce was able to
client. blood pressure - verbalize High-Fowler’s preload and - verbalize
- Blurred vision (90/60mmHg). understanding of the ventricular understanding of the
disease process and filling when disease process and
OBJECTIVE DATA: individual risk factors fluid overload is individual risk factors
- Light (Blurred vision, light the cause. (Blurred vision, light
headedness headedness) headedness)
- Pale in - display slight - Ensure patient - Restriction of - display slight
appearance improvement in vital remains on bed activity often improvement in vital
- Weakness sign. rest or facilitates sign.
- Delayed maintains temporary
capillary refill activity level recompensation
(5 seconds) Long Term: that does not
At the end of 3 weeks compromise Long Term:
VS taken as: of effective nursing cardiac output. After 3 weeks of
BP- 90/60mmHg intervention, the client effective nursing
(hypotensive) will be able to: - Provide a quiet - Psychological intervention the client

Transforming Communities through Science and Contact No: (044) 463-0825

Technology
Email: neustmain@neust.edu.ph
www.neust.edu.ph
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED
COLLEGE OF NURSING
P- 70 bpm (Decreased - participate in environment: rest helps reduce are now able to
peripheral pulses) activities that reduce explain emotional stress, - participate in
R- 20 cpm cardiac workload, and therapeutic which can activities that reduce
T- 36.0 °C - demonstrate adequate management, produce cardiac workload, and
cardiac output as help the patient vasoconstriction - demonstrate adequate
evidenced by vital avoid stressful , elevating blood cardiac output as
signs within acceptable situations, pressure. evidenced by vital
limits listen and signs within acceptable
respond to limits
expressions of The Goal is Met
feelings.

- Provide health - to avoid serious

teachings to the complications
client about the
actions and
precautionary
measures such
as: taking
medications at
the right time,
avoid too much
activities etc.

- Provide health - Early

teaching to the recognition of
family symptoms

Transforming Communities through Science and Contact No: (044) 463-0825

Technology
Email: neustmain@neust.edu.ph
www.neust.edu.ph
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED
COLLEGE OF NURSING
members such facilitates early
as: on how to problem solving
take VS at and prompt
home, and treatment.
information on
medications

- Encourage - For acute HF,

active and bed rest may be
passive temporarily
exercises. indicated.
Increase Otherwise, a
activity as total of 30
tolerated. minutes of
physical activity
every day
should be
encouraged
Dependent:
- Administer - Inotropic agents
medications as such as
prescribed, milrinone,
noting side digoxin,
effects and dopamine, and
toxicity. dobutamine are
used to increase
the force of

Transforming Communities through Science and Contact No: (044) 463-0825

Technology
Email: neustmain@neust.edu.ph
www.neust.edu.ph
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED
COLLEGE OF NURSING
cardiac
contractions.

- Administer - The failing heart

oxygen therapy may not be able
as prescribed to respond to
increased
oxygen
demands.
Oxygen
saturation need
to be greater
than 90%.

Collaborative:
- Associate - A thoroughly
patient to heart monitored
failure program exercise
or cardiac program can
rehabilitation improve both
program for functional
education, capacity, and
evaluation, and left ventricular
guided support function.
to increase

Transforming Communities through Science and Contact No: (044) 463-0825

Technology
Email: neustmain@neust.edu.ph
www.neust.edu.ph
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED
COLLEGE OF NURSING
activity and
rebuild life.

Im Rhodessa Kym D. Ronquillo and I will discussed the continuation of objective data

- Weakness, So basically the patient is weak because as heart

failure becomes more severe, the heart is unable to pump the
amount of blood required to meet all of the body's needs.
To compensate, blood is diverted away from less-crucial areas,
including the arms and legs, to supply the heart and brain.
That is why weakness are often accompanied by a feeling
of heaviness in the limbs and are generally related to poor
perfusion of the skeletal muscles in patient with a decreased cardiac output.

Transforming Communities through Science and Contact No: (044) 463-0825

Technology
Email: neustmain@neust.edu.ph
www.neust.edu.ph
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED
COLLEGE OF NURSING

- Delayed capillary refill (5 seconds)

A Capillary Refill Time longer than 2 seconds suggests poor
perfusion due to peripheral vasoconstriction. Peripheral vasoconstriction
is an appropriate response to low circulating blood volume and reduced oxygen delivery to vital tissues.

Vital signs taken:

- BP- 90/60mmHg (hypotensive)
So by reducing ventricular filling time, can cause a large reduction
in stroke volume and therefore cardiac output.
Ventricular fibrillation causes cardiac output to fall to zero, and therefore leads to hypotension.

- Pulse rate of 70 bpm

Impaired blood flow due to a variety of conditions,
such as heart failure, might be indicated by diminished
or absent pulses in the various arteries examined.
Bruits are the rushing sounds heard in large and medium-sized
arteries as a result of turbulent blood flow causing vibration in the arterial wall.
In general, bruits are not audible until an artery is approximately 50% occluded.
Thereafter, the sound may no longer be detectable as the volume of blood flow
becomes greatly reduced so that is why the patient has decreased peripheral pulses.

- Respiratory rate of 20 cpm which is normal

Transforming Communities through Science and Contact No: (044) 463-0825

Technology
Email: neustmain@neust.edu.ph
www.neust.edu.ph
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines
ISO 9001:2015 CERTIFIED
COLLEGE OF NURSING

- And a Normal temp. of 36*C

Transforming Communities through Science and Contact No: (044) 463-0825

Technology
Email: neustmain@neust.edu.ph
www.neust.edu.ph