ASSESSMENT NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EXPECTED

DIAGNOSIS EXPLANATION OUTCOMES

SUBJECTIVE: Decreased Cardiac A ventricular septal SHORT TERM: INDEPENDENT: SHORT TERM:
The patient’s mother Output related to defect (VSD) occurs After 1 hour of nursing Check the blood In response to After 1 hour of nursing
verbalized: altered afterload as when the wall between education, the parent pressure and heart rate decreased cardiac education, the parent
“I noticed that my child is
evidenced by the two ventricles does will verbalize of Jason. activity, most patients shall have verbalized
having difficulty of occasional not completely develop understanding of the develop understanding of the
breathing” breathlessness, during gestation, disease process, and compensatory disease process, and
dyspnea, recurrent resulting in a hole. One treatment plan. tachycardia and treatment plan.
“He also sweats and has wheezing, sweating, form of congenital heart dramatically low blood
rapid breathing when I breathing fast when defect is a ventricular pressure.
feed him.” feeding, tachycardia, septal defect. Blood LONG TERM: LONG TERM:
tachypnea, and low often passes from the After 24 hours of After 24 hours of
oxygen saturation left ventricle through nursing Check for his capillary Reduced stroke nursing
the VSD to the right care/interventions, the refill and peripheral volume and cardiac care/interventions, the
OBJECTIVE: ventricle and into the mother will report that pulses. output trigger weak mother shall have
The patient manifested lungs in babies with her child has pulses. Capillary refill reported that her child
the ff: VSD. Since there is decreased episodes can be sluggish or has decreased
more blood pumped of dyspnea, normal non-existent at times. episodes of dyspnea,
Physical examination: - into the lungs, the heart heart rate, respiratory normal heart rate,
Recurrent wheezing and lungs have to work rate, normal oxygen respiratory rate,
- Sweating harder. level, and increased Examine him for signs of Low cardiac output normal oxygen level,
- Fast breathing on activity tolerance exhaustion and levels are associated and increased activity
feeding without experiencing decreased activity with fatigue and tolerance without
- Heard a loud, harsh, Decreased Cardiac dyspnea, rapid tolerance. exertional dyspnea. experiencing dyspnea,
holosystolic murmur at Output is insufficient breathing when The patient's reaction rapid breathing when
the left lower sternal blood pumped by the eating, and is closely monitored eating, and tachypnea.
border during heart to satisfy the tachypnea. as a guide for the
auscultation body's metabolic effective progression
demands. Multiple of activity.
Vital Signs: factors influence
- HR: 140bpm cardiac output and
- RR: 44bpm pinpointing the exact Check Jason for gallops S3 is a class sign of
cause of decreased by listening to your ears left ventricular failure
Laboratory Findings: cardiac output can be (S3, S4). that shows decreased
- SPO2: 92% difficult. Reduced left ventricular
- Chest X-ray: cardiac output can ejection. S4 is
• Cardiomegaly happen unexpectedly characterized by
with plethoric or gradually over time. decreased left
lung filed ventricle compliance,
- Ultrasound: Decrease Cardiac which impairs
• Enlarged liver Output is applicable in diastolic filling.
- 2D-Echo revealed: Jason’s condition. He is
having trouble
• 6.3 mm in the left breathing and isn't
ventricle outflow getting enough oxygen Allow him to get enough Rest reduces
tract beneath the (SPO2 level is 92 time for rest. metabolic rate, which
aortic valve percent ). Sweating and lowers myocardial
• Dilated Left rapid breathing were and oxygen demand.
Ventricle also observed during
• Severe Tricuspid feeding, as well as a
Regurgitation rapid heart rate of 140 Provide psychological When the client and
• Pulmonary Blood beats per minute and a support to the client and significant others are
Pressure: respiratory rate of 44 significant others. facing a lot of activity
45mmHG beats per minute, which Maintain a peaceful and "worry," honesty
are both compensatory atmosphere, but can be helpful.
mechanisms of the acknowledge any worries
body which increase its if they have any
size to allow more questions.
blood to fill the ventricle
before it pumps,
allowing more blood to
fill the ventricle before it
pumps. This type of
compensation can be
beneficial at first, but as DEPENDENT:
the heart grows larger, Follow the doctor's Increased oxygen
more strain builds on instructions for oxygen demands can be too
the heart's walls as it therapy. much for the failing
pumps blood out. heart to
Hypertrophy of the accommodate. The
heart muscle, on the oxygen saturation
other hand, increases level must be held
the heart's demand for between 97 and 99
nutrients and oxygen. percent.
These demands can
ultimately outstrip the
heart's blood supply, Administer drugs as Treatment will be
causing the heart directed by your doctor: determined by the
muscle to weaken symptoms, age, and
further. Furthermore, overall health of the
hypertrophy of the infant. It can also be
heart's walls can determined by the
intensify diastolic severity of the
dysfunction by disease.
impairing the heart's
ability to relax properly.
This reduces the ⚫ Diuretics such as ⚫ To aid in the
heart's capacity to Furosemide (Lasix); elimination of
pump blood. spironolactone fluid and the
(Aldactone) reduction of
 after-load. Also,
check the intake
and output, as
well as the
electrolytes,
especially the
potassium
levels.

⚫ Digoxin ⚫ Increases the

heart's
contractility and
force of
contraction,
allowing the
heart to pump
more forcefully
but at a slower
pace.
Furthermore,
the apical pulse
should be
measured for 1
minute and the
heart rhythm
should be noted;
vomiting could
indicate toxicity

⚫ ACE Inhibitors ⚫ To assist in

such as Capoten lowering the
pressure in the
left ventricle and
reducing blood
shunting into the
right ventricle

INTERDEPENDENT:

Rate, rhythm, and ectopy Low perfusion,

should all be monitored acidosis, or hypoxia
on an electrocardiogram may all-cause cardiac
(ECG). dysrhythmias. Ectopic
beats, tachycardia,
and bradycardia may
 all reduce cardiac
production.

Check the status of To collect baseline

laboratory results, such data and to look for
as CBCs, ABGs, cardiac other illnesses that
biomarkers, kidney, could be linked to
thyroid, and liver function VSD.
tests.

Inform the mother and They must be

other SO about the VSD sufficiently informed
disease mechanism and about the child's
risk factors. condition and adhere
to the care plan
promptly.

Inform and educate the If the child is exposed

mother on how to to infected individuals,
minimize being exposed his or her health could
to infected patients. be jeopardized. To
avoid respiratory
infection (preventive
vaccines are needed)
and to reduce the risk
of endocarditis,
prophylactic
antibiotics may be
required.

Teach and inform It is important to

parents about the educate them about
different ways and the benefits of small,
significance of improving regular feedings,
their child's nutrition. high-calorie formula
or breast milk, and
the need for
supplementary tube
feedings.
 REFERENCES:
5 Congenital Heart Disease Nursing Care Plans - Nurseslabs. (2017, December 29). Nurseslabs. https://nurseslabs.com/5-congenital-heart-disease-nursing-care-
plans/#decreased_cardiac_output
Decreased Cardiac Output – Nursing Diagnosis & Care Plan. (2016, October 3). Nurseslabs. https://nurseslabs.com/decreased-cardiac-output/
Heart Failure: Compensation by the Heart and Body | Michigan Medicine. (2020). Uofmhealth.org. https://www.uofmhealth.org/health-library/aa86963