DULNUAN DCM NCP.pdf - FOCUS /Nursing Diagnosis Expected...

FOCUS
/Nursing
Diagnosis
Expected
Outcome/s (of
PRIORITY
diagnosis)
PLAN: Nursing
Interventions
Rationale
1. Decreased
cardiac output
related to impaired
ventricular filling,
contractility, or
outflow obstruction
as evidenced by
tachycardia,
dysrhythmias, and
hypotension.
2. . Impaired gas
exchange alveolar
edema secondary to
increased ventricular
pressure as
evidenced by
dyspnea, orthopnea,
and DOB even at
rest.
3. Ineffective tissue
perfusion related to
poor cardiac output
as evidenced by
cyanosis on oral
mucosa and nail
beds, generalized
weakness, and pitting
edema on abdomen
and both extremities.
Priority: According to
ABC, maintaining
circulation is
important in moving
oxygen to the tissues
and carbon dioxide
out of the body. Aside
from that, addressing
this problem may
affect/address as well
the other identified
problems.
LTO: After 3 days of
nursing interventions, the
patient will demonstrate
adequate cardiac output
as evidenced by BP of at
least 110/80, PR of
60-100, dysrhythmias
controlled, urinary output
of increase to at least
300-500 ml.