NURSING CARE PLAN OF MR.
A PATIENT WITH
A. IDENTITY
Name : Mr. B
B. Case Review
1. Chief complaint : Mr. B had a shortness of breath
2. History of Present Ilness : Mr. B was brought to emergency department
withseveral complaints. He had a shortness of breath since a week before
admission and doing activities made it worse. Two days before he was admitted to
the hospital, his shortness of breath was getting worse. He also loss of appetite.
3. Past Medical History : Mr. B has no past medical history
4. Family History : Mr. B has no family history
5. Physical Examination
a. Vital Sign
BP : 110/70 mmHg
P : 92 bpm
RR : 32 breath/minute
T : 360 C
b. Facial Examination
Mr. B had Cyanosed Lips and Pale face
c. Neck : JVP 5 + 4 cm
d. Extremity Examination
Mr. B had swollen legs
Lower extremity edema +/+
Capillary refill : 5 second
6. Additional Data
a. Ro Thorax : Cardiomegaly
b. Echocardiography: EF 52 %
C. DATA ANALYSIS
1. Data Clustering
No Focus Data Problem Etiologi
1 SD : Decreased
He had a shortness of Cardiac Output
breath since a week before (00029)
admission
Doing activities made it
worse
OD :
RR : 32 breath/minute
BP : 110/70 mmHg
Cyanosed Lips
Pale face
JVP : 5 + 4 cm
Swollen legs
Lower extremity edema +/
+
Echocardiography : EF 52
%
Ro Thorax : Cardiomegaly
2. Nursing Outcome
No. Nursing Diagnosis Expected Outcome
1. Decreased Cardiac After the nursing implementations for 2x24 hours,
Output (00029) the client will achieve :
realeted to 1. Cardiac output effectiveness (0400) as
evidence by :
- Systolic blood pressure from level III to
level IV
- Diastolic blood pressure from level III to
level IV
- Neck vein distension from level 2 to level
4
- Peripheral edema from level 3 to level 4
Informations :
I = severe deviation from normal range
II = subtantial deviation from normal range
III = moderate deviation from normal range
IV = mild deviation from normal range
V = no deviation from normal range
1 = severe
2 = substantial
3 = moderate
4 = mild
5 = none
2. Circulation status (0401) as evidence by :
- Capillary refill from level 2 to level 4
Informations :
I = severe deviation from normal range
II = subtantial deviation from normal range
III = moderate deviation from normal range
IV = mild deviation from normal range
V = no deviation from normal range
3. Nursing Intervention
No. Expected Outcome Nursing Intervention
1. After the nursing Cardiac Care (4040)
implementations for Monitor EGC for ST changes, as
2x24 hours, the client appropriate.
will achieve : Perform a comprehensive appraisal of
peripheral circulation (i.e, check peripheral
1. Cardiac output pulses, edema, capillary refill, color, and
effectiveness temperature of extremity) routinely per
(0400) agency policy.
2. Circulation Monitor vital signs frequently.
status (0401) Note signs and symptoms of decreased
cardiac output.
Provide antiarrhythmic therapy according
to unit policy (e.g, antiarrhythmic
medication, cardioversion, or
defibrillation), as appropriate.
Arrange exercise and rest periods to avoid
fatigue.
Monitor the patient’s activity tolerance.
