NURSING CARE PLAN

CONGESTIVE HEART FAILURE- DEEP VEIN THROMBOSIS

Prepared by:
Barazan, Riza Angela A.
Guintadcan, Allyssa A.
Suminguit, Anna Mae E.-B1

Submitted to:
Asst. Prof. Leila Joy T. Cazon

December 04, 2020

 PATIENT’S PROFILE

Name: R.L.R Civil Status: Married Sex: Male Educational Attainment: College Graduate
Address: Jimalalud Neg Or._ Religion: Roman Catholic Age: 39 years old Occupation: PNP Officer Room and Bed No.: Room 344
Doctor(s) in Charge: Dr. S Nationality: Filipino Date and Time of Admission:
Chief Complaints: Dyspnea
Diagnos(es): _ Admitting Dx: R/o Pulmonary Vasculitis; Antiphospholipid Syndrome; r/o Pneumonia
Discharge Dx: CHF non-specified; Respiratory Tract Infection d/t External Agent; Deep Vein Thrombosis
General Impression of client (appearance upon first contact):
Patient lying on bed in Semi-fowler’s position with D5NM iL infusing @ right metacarpal vein @660 cc level. Appears tired with hyperpigmented
necrotic bilateral leg with white socks. Speech is coherent, voice is well modulated, well-groomed.
History of Present Illness:
− 2 days PTA, had onset of productive cough with frothy pink sputum with occasional dyspnea. Had also 2 episodes of vomiting composed of food particles.
Tolerated condition.
− A day PTA, persistence of cough and dyspnea with undocumented fever. Self-medicated with Paracetamol and started on Oxygen @ 2lpm via nasal
cannula which offered minimal relief. Persistence of symptoms prompted admission.
Patient Medical History
− Nonhypertensive, nondiabetic, nonasthmatic. Diagnosed with Deep Vein Thrombosis and maintained on Warfarin but was stopped d/t thrombocytopenia. In
2014, was diagnosed with Antiphospholipid Syndrome

Previous Admissions
− 2010- Deep Vein Thrombosis
− 2010-2014: 3 admissions
− 2014- Antiphospholipid Syndrome
− January 9, 2019- diagnosed with Pneumonia on right lung
 CUES/EVIDENCES NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Subjective: Independent: At the end of my 8-hour
Ineffective breathing Goal: − Monitor vital signs - To serve as baseline 2 days of nursing care,
• Dyspnea or pattern r/t pulmonary especially respiration rate data and to determine the goals and objectives
SOB occurs congestion secondary At the end of my 8- and pulse rate if there are any were fully met as
when voiding or to Pneumonia hour 2 days of nursing abnormalities. evidenced by:
standing to long care in the medicine 1. Respiratory rate
as verbalized. ward, the client will be − Utilize pulse oximeter to - Pulse oximetry is a remained normal
able to show: check oxygen saturation helpful tool to detect and O2 sat. is
and pulse rate. alterations in within 97%.
Objectives: 1. Maintain effective oxygenation initially; 2. Performed
• Productive breathing pattern but, for CO2 levels, diaphragmatic
cough, had little as evidenced by end tidal CO2 pursed lip
amount of red normal respiration monitoring or arterial breathing.
discharges with rate and depth blood gases (ABGs) 3. Effectively
greenish mucus without using would require being expectorated
(1.5-2 ml) accessory obtained. sputum after
• Frothy pink muscles and any − Record thoracic deep breathing
sputum assistive device. movements observing the - To check symmetry and coughing
• Fatigue and 2. Perform existence of symmetry, and see the contraction exercises.
diaphragmatic use of accessory muscle of diaphragm. Normally
lethargic 4. Demonstrated
• Decreased pursed-lip and retractions of the middle finger of maximum lung
activity level breathing. supraclavicular and both hands separates expansion with
3. Tolerate ADL’s intercostal muscles. as patient inhales and
• Presence of adequate
with breathing return during
nasal cannula ventilation.
pattern normal. exhalation.
for O2 5. Tolerated the
4. Effectively
inhalation @2- discontinuation of
expectorate − Evaluate skin color,
LPM. oxygen therapy
• Pallor is noted
sputum. temperature, capillary - Lack of oxygen will as evidenced by
refill; observe central cause blue/cyanosis stable respiratory
in skin
 versus peripheral coloring to the lips, rate of 20 cpm
cyanosis. tongue, and fingers. and O2 sat. of
Vital Signs: 97%
• T: 36.8 °C − Place patient in semi or
• PR: 62 bpm high fowler position. - To allow and promote The goals and objectives
• RR: 21 cpm effective breathing and were partially met as
• BP: 110/80 lung expansion. evidenced by:
mmHg − Assess ability to mobilize 1. There is no recent
secretions. - The incapability to chest XRAY
mobilize secretions result therefore,
Radiologic Report: may contribute to was not able to
• Pneumonia, change in breathing check again if
left, significant pattern there is still any
regressed with presence of
minimal pleural − Demonstrate and assist haziness in left
effusion, right. patient in doing deep - To facilitate and ensure middle lung and
• Hazy densities breathing and coughing accuracy of the minimal pleural
affect left mid exercises. procedure. effusion at right
lung. 1. Instruct patient to lung.
inhale through nose 2. Patient still needs
with mouth close. minimal
2. Exhale through assistance in
pursed lips slowly for terms of ADL’s.
6-10 seconds.
3. Facilitate coughing on
the 3rd deep
breathing. Allow
patient to inhale and
hold breath for 3
seconds then exhale
slowly.

− Offer tissue and mouth

care. - To ensure comfort after
the procedure.
− Encourage ambulation if
tolerated or do assisted - To help further break
ROM up and move
secretions.
− Encourage patient to
drink at least 1 liter of - Liquids can help
water to be hydrated. facilitate secretions.

− Manipulate the
environment of patient’s - To ensure comfort of
room. Provide a calm, client and ensure good
well ventilated room and resting period.
instruct parents or
“bantay” to let the patient
wear loose clothing as
possible.

Dependent:
− Give supplemental - Increases the amount
oxygen with 2 LPM as of oxygen in the lungs
ordered by the doctor received and deliver to
the blood.

− Chest Physiotherapy as - To move fluid or mucus

ordered. in the lungs. It is done
by tapping on the chest
and by positioning the
patient to help move
mucus to the larger
airways where it can be
coughed and/or
suctioned out.
 - Administer medications as - To assist/help patient
ordered pharmacologically to
be relieved or cured.

CUES/EVIDENCES NURSING OBJECTIVES INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Objectives: Independent: At the end of my 8-hour
• Presence of Ineffective peripheral Goal: − Assess for the signs and − The signs and 2 days of nursing care,
deep vein tissue perfusion r/t symptoms of deep vein symptoms occur in the the goals and objectives
thrombosis as interruption of venous At the end of my 8- thrombosis (DVT). leg affected by the were partially met as
evidence by blood flow. hour 2 days of nursing deep vein clot which evidenced by:
bilateral legs care in the medicine includes swelling, pain 1. Thrombosis is still
• No bipedal ward, the client will be or tenderness, present; however,
pulses able to show: increased warmth, and px maintained
• Presence of changes in skin color optimal peripheral
pallor is noted 1. Maintain optimal (redness). tissue perfusion
on skin. peripheral tissue − Assess presence, − Useful in identifying or in the affected
• Redness, perfusion in the location, and degree of quantifying edema or extremity as
swelling in the affected extremity, swelling or edema thrombosis in evidenced by
affected leg as evidenced by formation. extremity. strong palpable
noted; warm to strong palpable pulses, reduction
touch pulses, reduction in − Measure the − Unilateral leg and thigh of pain, redness
and/or absence of circumference of the swelling can be and swelling of
Laboratory Results: pain, warm, and affected leg with a tape assessed by affected leg
CBC: dry extremities, measure. measuring the 2. So far, the patient
and adequate
• Platelet: 29 circumference of the has not
capillary refill. affected leg 10 cm complained and
T/cumm
2. Will not experience below the tibial reported
Coagulation Test:
pulmonary tuberosity and 10 cm to
• PT test: 17.9 dyspnea, chest
embolism, as 15 cm above the upper pain and no signs
sec.
evidenced by edge of the patella.
• INR: 1.51 normal breathing,
of pulmonary
Deep vein thrombosis embolism.
normal heart rate, is suspected if there is
Activated partial and absence of
thromboplastin: a difference of >3 cm The goals and objectives
dyspnea and chest between the were fully met as
• PT test: 62 sec pain. extremities.
• Control: 31.6 3. Demonstrate evidenced by:
− To determine
sec behaviors and − Measure capillary refill adequacy of systemic 1. Patient verbalized
lifestyle changes to circulation
improve the importance of
− These are used to exercises,
circulation. (e.g. measure the
engage in regular cessation of
exercise, cessation − Monitor the following effectiveness of smoking and
of smoking, coagulation profile: anticoagulant therapy. having a healthy
disease reduction) • International The PT/INR is used for and regular diet
normalized ratio (INR) clients receiving after listening to
• Prothrombin time (PT) warfarin. Baseline structured health
• Partial thromboplastin values are obtained teaching. Able to
time (PTT) before the first dose of enumerate at
anticoagulant is least some of the
administered. effects of not
maintaining a
adequate − Hydration prevents an
healthy lifestyle.
− Maintain
hydration. increased viscosity of
blood, which
contributes to venous
stasis and clotting.
− Check for calf tenderness − Indicators of deep vein
or pain in dorsiflexion of thrombosis (DVT),
foot (Homan’s sign), although DVT is often
swelling, and redness. present without a
positive Homan’s sign.
− Encourage bedrest and − Clients usually require
keep the affected leg bed rest until
elevated (depending on symptoms are relieved.
size and location of the The affected leg should
clot) as indicated. be elevated to a
position above the
heart to decrease
Dependent: swelling.

− Apply below-knee − Compression

compression stockings as stockings enhance
prescribed. Ensure that circulation by providing
the stockings are the a graduated pressure
correct size and are on the affected leg to
applied correctly. help return the venous
 blood to the heart.
Inaccurately applied
stockings can serve as
a tourniquet and can
promote clot formation.

− To promote optimal
− Administer fluids, blood flow, organ
electrolytes, nutrients, perfusion, and
oxygen as indicated or function.
ordered.
 CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION
Objectives: Independent: At the end of my 8-hour
− Low platelet count Risk for bleeding r/t to Goal: − Monitor patient’s vital − Hypotension and 2 days of nursing care,
on CBC which is 29 decreased blood clotting signs, especially BP and tachycardia are initial the goals and objectives
T/cumm factors as evidenced by At the end of my 8- HR. Look for signs of compensatory were fully met as
evidenced by:
− Appeared tired with low platelet count hour 2 days of orthostatic hypotension. mechanisms usually
hyperpigmented, 1- secondary to nursing care in the noted with bleeding.
thrombocytopenia medicine ward, the • Minimally
1.5 cm necrotic
client will be able to − Assess for signs of − Observe increase in
bilateral leg with skin for
(normal: 150-400 show: platelet
white socks. internal or external petechiae, purpura and
T/cumm) production as
− Pallor is noted on bleeding; blood in urine or open wounds.
1. Increase platelet evidenced by a
skin. stool, bleeding of mucous Bleeding may be
production and platelet count of
membranes such as minimal, non-existent
availability within 120 T/cumm
Vital Signs: gums, and skin. or severe.
normal range. • Client was able
• T: 36.8 °C
2. No signs of − Check stool (guaiac) and − These tests are used to to recognized
• PR: 62 bpm
bleeding and signs that need to
• RR: 21 cpm urine (Hemastix) for distinguish bleeding
recognizes signs be reported
• BP: 110/80 occult blood. from the
that need to be immediately to a
mmHg gastrointestinal or
reported health care
urinary tracts that may
immediately to a professional; did
not be visible.
health care − Assess skin and mucous − Patient with reduced not manifest any
professional. signs for bleeding
membranes for signs of platelet counts or
3. Normal blood • Blood pressure is
petechiae, bruising, impaired clotting factor
pressure, stable within normal
hematoma formation, or activity may
platelet levels and range, had
oozing of blood. experience bleeding
desired ranges for minimally stable
into tissues that is out
coagulation platelet levels and
of proportion to the
profiles. desired ranges
injury. Prolonged
 oozing of blood from for coagulation
surgical incisions or profiles.
areas of skin trauma is
associated with
coagulation
abnormalities.

− Review laboratory results − These laboratory tests

for coagulation status as provide important
appropriate: platelet information about the
count, prothrombin patient’s coagulation
time/international status and bleeding
normalized ratio potential. For patient’s
(PT/INR), and activated receiving
partial thromboplastin anticoagulants,
time (aPTT). increased levels of
PT/INR and aPTT
above therapeutic
values are associated
with increased risk for
bleeding.

− Maintain patency at − For fluid administration

vascular access or blood replacement
as indicated.

− Educate the patient and − Early evaluation and

family members about treatment of bleeding
signs of bleeding that by a health care
need to be reported to a provider reduce the
health care provider.
 risk for complications
− Monitor for skin necrosis, from blood loss.
changes in blue or purple − Patient on
mottling of feet that anticoagulant therapy
blanches with pressure or remains at risk of
fades when legs are developing emboli.
elevated.

− Educate the patient about

over-the-counter drugs − These drugs not only
and avoid products that decrease normal
contain aspirin or NSAIDs platelet aggregation
such as ibuprofen and but also decrease the
naproxen. integrity of gastric
mucosa through
inhibition of
cyclooxygenase
(COX)-1 inhibitor and
therefore increase the
risk for gastrointestinal
bleeding.
− Provide psychological
and emotional support to − This helps in patient’s
the patient. assurance and
calming.
− Teach patient to use only
an electric razor (not − To reduce risk of injury
blade for shaving) and which may prompt to
encourage use of soft- bleeding.
bristle toothbrush, mild
 mouthwash also, avoid
floss.
− Instruct client to avoid − These activities can
forceful blowing, damage mucous
coughing, sneezing and membrane increasing
straining to have a bowel risk of bleeding.
movement.

Dependent:
1. Anticipate blood − Your blood carries
transfusion and assist oxygen and nutrients to
in the procedure. all parts of your body.
Blood transfusions
replace blood that is
lost through surgery or
injury or provide it if
your body is not
making blood properly.
 CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION
Subjective: Activity intolerance r/t to Independent: At the end of my 8-hour
Mild dyspnea or imbalance between Goal: − Monitor vital sign (Blood − To have baseline data. 2 days of nursing care,
shortness of breath will oxygen supply and Pressure, pulse, and Cardiopulmonary the goals and objectives
occur when he will go demand. At the end of my 8- respirations) during and manifestations result were fully met as
to the comfort room to hour 2 days of after activity. from attempts by the evidenced by:
defecate or even for nursing care in the heart and lungs to
1. Patient tolerated
standing too long, as medicine ward, the supply adequate the assisted range
verbalized. client will be able to: amounts of oxygen to of motion exercises
the tissues. and the deep
Objectives: 1. Perform daily breathing and
− Assess patient ability to coughing
− Needs assistance activities on its − Influences choice of
perform ADLs exercises.
in doing self-care own without interventions and 2. Verbalized positive
activities such as getting assistance needed assistance. response to adhere
bathing, dressing, from anybody or to the activities
and grooming. any devices. − Assess the need for − Assistive devices planned as stated,
− Lethargic and ambulation aids (e.g., enhance the mobility of “Ganahan ko ug
2. To provide cane, walker) for ADLs. ingon ani Ma’am
fatigue the patient by helping
positive verbal aron maulian
− Presence of him overcome nako”.
feedback in
hyperpigmented, 1- response to limitations. 3. Patient was able to
1.5 cm necrotic activity level maintain regular
bilateral leg with − Determine patient's cardiovascular and
white socks. 3. To perform basic perception of causes of − Aids in defining what respiratory during
activity intolerance. and after functions
− Lack of sleep, activities without patient is capable of, as evidenced by
maximum of 4 excessive which is necessary
exhaustion or loss RR: 20 CPM; PR:
hours. before setting realistic 70 BPM, and O2
of energy
− Establish guidelines and goals. SAT: 97%.
Functional Level 4. Maintain regular goals of activity with the
Code: cardiovascular patient and/or SO − Motivation The goals and objectives
and
− Feeding: 1 and respiratory (Significant Other/s) were partially met as
cooperation are
− Bathing: 1 evidenced by:
enhanced if the patient
− Toileting:1 functions during participates in goal
− Bed Mobility: 1 activities − Have the patient perform setting. 1. Patient still need
the activity more slowly, in minimal assistance
a longer time with more − Helps in increasing the on activities on
Vital Signs:
rest or pauses, or with daily living and
• T: 36.8 °C tolerance for the doing self-care as
assistance if necessary.
• PR: 62 bpm activity evidenced by:
• RR: 21 cpm − Encourage conscious-
• BP: 110/80 controlled breathing Functional Level Code:
techniques (e.g., pursed- Feeding: 1
mmHg
lip breathing and Bathing: 1
diaphragmatic breathing) Toileting:1
− To facilitate lung Bed Mobility: 1
during increased activity
and times of emotional or expansion and reduces
physical stress. stress for it promote
relaxation
− Gradually increase
activity with active range-
of-motion exercises in
bed, increasing to sitting
and then standing.
− Gradual progression of
− Dangle the legs from the the activity prevents
bed side for 10 to 15 overexertion.
minutes.

− Prevents orthostatic
− Provide bedside
hypotension.
commode as indicated.

− Use of commode
requires less energy
expenditure than using
− Encourage verbalization a bedpan or
of feelings regarding ambulating to the
limitations. Also, provide bathroom.
emotional support and
positive attitude regarding
abilities. − This helps the patient
to cope.
Acknowledgment that
living with activity
intolerance is both
physically and
emotionally difficult.
− Refrain from performing Appropriate
nonessential activities or supervision during
procedures. early efforts can
enhance confidence.

− Patient with limited

− Encourage active ROM
activity tolerance need
exercises. Encourage the
patient to participate in to prioritize important
planning activities that tasks first.
gradually build
endurance.
− Exercise maintains
muscle strength, joint
ROM, and exercise
tolerance. Physical
inactive patients need
to improve functional
capacity through
repetitive exercises
− Promote rest and comfort. over a long period of
 time. Strength training
is valuable in
enhancing endurance
− Educate patient and of many ADLs.
family members on
lifestyle choices, healthy
habits and the importance
of regular physical activity − To conserve energy.
in daily life.

− Teach patient/caregivers
− To have an
to recognize signs of
physical overactivity. understanding why it
needs to be done in
− Demonstrate and assist order to have effective
patient in doing deep outcome.
breathing and coughing
exercises.
o Instruct patient to
inhale through
nose with mouth − Promotes awareness
close. of when to reduce
o Exhale through activity.
pursed lips slowly
for 6-10 seconds.
− Helps in performing
o Facilitate coughing
on the 3rd deep efficient breathing by
breathing. Allow maximizing the
patient to inhale expansion of the lungs
and hold breath for and facilitate
3 seconds then movement of
exhale slowly. secretions
Dependent:
1. Administer oxygen as
ordered.

− Increases the amount

of oxygen in the lungs
received and deliver to
the blood.