how to make NCP for Congestive heart failure

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I've been searching all day long on how to make a nursing care plan to my pt., 88 years old she was diagnosed CAP- MR CONGESTIVE HEART FAILURE. Tbh, it's really difficult to make an NCP for this because i didn't interview the patient because she was on ICU that day can't speak because she intubated, has NGT with 02. I'm still a student nurse need seriously help from this site :( i hope to hear from this site please help me what should i put to my NCP

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My pt. has been diagnosed with CAP MR CONGESTIVE HEART FAILURE , she's intubated, NGT with o2 and my nsg dx are:

>Decreased cardiac output

>Impaired gas exchange

>Ineffective breathing pattern

>Ineffective tissue perfusion

i don't know if all of these nsg dx are applicable to my patient. i have doubts. because we had a case presentation last week and then they omit my output. Because i don't how to relate this nsg dx. also how to make a planning.

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Specializes in ER/Tele, Med-Surg, Faculty, Urgent Care.

OK, we won't do your homework for you but will guide you. What have you written for your draft? No need to interview her. Start with the Basics, Get your NANDA book out, using Maslow as a guide where would you start?

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Specializes in Public Health, TB.

Your nursing diagnoses should be based on your assessment, not on the medical diagnoses. Do you have vital signs including pulse oximetry? Heart and lung sounds? labs and/or imaging?

Why are you choosing decreased cardiac output? What assessments lead you to that?

Gas exchange is often based on a particular set of labs. Do you know what they are?

Don't forget to look at other body systems, again, based on your assessment. How are her kidneys? If she has and NGT, how is she getting hydration and nutrition? What is her neuro status? Does she move independently? Is she in pain?

Once you have your nursing diagnoses, you can create goals, and steps to achieve those goals. If she has decreased cardiac output, what would be your goal for her? How would you go about achieving that?

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Specializes in Education, FP, LNC, Forensics, ED, OB.

Welcome to allnurses.com

Duplicate threads merged and moved to Nursing Student Assistance forum.

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Without assessments, you really cannot come up with nursing diagnoses. Checking pt's labs, I&Os, current medications, and doing a head to toe assessment are ways of gathering valuable information that can guide you in writing a care plan without actually talking to the pt.

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