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    NCP For CHD

    Uploaded by

    Monica Rivera
    The nursing care plan outlines goals and interventions for a person with congenital heart disease. The plan aims to improve cardiac output by closely monitoring vital signs, skin appearance, peripheral pulses and activity tolerance. Rest, positioning and oxygen therapy are prescribed to decrease metabolic demands on the heart. The goal is to achieve normal hemodynamics, including blood pressure, pulse and peripheral pulses within one week.

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    NCP For CHD

    Uploaded by

    Monica Rivera
    965 views2 pages
    The nursing care plan outlines goals and interventions for a person with congenital heart disease. The plan aims to improve cardiac output by closely monitoring vital signs, skin appearance, peripheral pulses and activity tolerance. Rest, positioning and oxygen therapy are prescribed to decrease metabolic demands on the heart. The goal is to achieve normal hemodynamics, including blood pressure, pulse and peripheral pulses within one week.

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    Nursing Care Plan for CHD

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    NCP FOR CHD

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    The nursing care plan outlines goals and interventions for a person with congenital heart disease. The plan aims to improve cardiac output by closely monitoring vital signs, skin appearance, peripheral pulses and activity tolerance. Rest, positioning and oxygen therapy are prescribed to decrease metabolic demands on the heart. The goal is to achieve normal hemodynamics, including blood pressure, pulse and peripheral pulses within one week.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    965 views2 pages

    NCP For CHD

    Uploaded by

    Monica Rivera
    The nursing care plan outlines goals and interventions for a person with congenital heart disease. The plan aims to improve cardiac output by closely monitoring vital signs, skin appearance, peripheral pulses and activity tolerance. Rest, positioning and oxygen therapy are prescribed to decrease metabolic demands on the heart. The goal is to achieve normal hemodynamics, including blood pressure, pulse and peripheral pulses within one week.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    NURSING CARE PLAN FOR A PERSON WITH CONGENITAL HEART DISEASE

    CUES
    Subjective Cues: None
    Objective Cues: None
    NURSING DIAGNOSIS
    Decreased Cardiac Output related to structural factors of congenital heart defect as
    manifested by variations in hemodynamic readings, widened pulse pressure, arrhythmias,
    and decrease peripheral pulses.
    INFERENCE
    Congenital Heart Disease is a malformation of the heart existing at birth and results
    from malformations of the heart that involve the septums, valves, and large arteries. They
    are classified as acyanotic or cyanotic defects. Acyanotic defects occur when a left-to-
    right shunt is present that allows a mixture of oxygenated and unoxygenated blood to enter
    the systemic circulation. The most common consequences of these defects in children are
    growth retardation and congestive heart failure (CHF).

    NURSING GOAL AND OBJECTIVE

    At the end 1 week of nursing intervention, the client will:


     Be able to demonstrate adequate cardiac output
     Have blood pressure, pulse rate, and heart rhythm within normal parameters
     Have normal peripheral pulse
    NURSING INTERVENTION AND RATIONALE

    NURSING INTERVENTION RATIONALE


    Assess heart rate and blood pressure. Most patients have compensatory
    tachycardia and significantly low blood
    pressure in response to reduced cardiac
    output.
    Note skin color, temperature, and moisture Cold, clammy, and pale skin is secondary to
    a compensatory increase in sympathetic
    nervous system stimulation and low cardiac
    output and oxygen desaturation.
    Check for peripheral pulses, including Weak pulses are present in reduced stroke
    capillary refill. volume and cardiac output. Capillary refill is
    sometimes slow or absent.
    Assess for reports of fatigue and reduced Fatigue and exertional dyspnea are
    activity tolerance common problems with low cardiac output
    states. Close monitoring of the patient’s
    response serves as a guide for optimal
    progression of activity
    Inspect fluid balance and weight gain. Compromised regulatory mechanisms may
    Weigh patient regularly prior to breakfast. result in fluid and sodium retention; Weight
    is an indicator of fluid balance.
    Assess heart sounds for gallops (S3, S4) S3 indicates reduced left ventricular
    ejection and is a class sign of left ventricular
    failure. S4 occurs with reduced compliance
    of the left ventricle, which impairs diastolic
    filling
    Provide adequate rest Rest decreases metabolic rate, decreasing
    myocardial and oxygen demand.
    Position child in Semi-Fowler’s position Upright position is recommended to reduce
    preload and ventricular filling when fluid
    overload is the cause; Facilitates lung
    expansion.
    Administer oxygen therapy as prescribed The failing heart may not be able to
    respond to increased oxygen demands.
    Oxygen saturation need to be greater than
    90%

    EVALUATION
    After rendering nursing intervention, the client

     Demonstrate adequate cardiac output


     Blood pressure, pulse rate, and heart rhythm are within normal parameters
     Has normal peripheral pulse
    Thus, the goal was totally met.

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