NURSING DIAGNOSIS

GOALS Short Term & Long term

INTERVENTIONS

Rationale for Interventions

EVALUATION OF GOALS
,oal 1et2 1edications wor3ed effectivel! and i+proved the patient4s condition" with no nota-le side effects.

1edications will help the Ad+inister +edication patient return to -aseline as ordered -! ph!sician levels" -ut need to -e and +onitor +onitored due to serious side effectiveness. effects. (Potter Perr!" #$$%" p. &'() 1onitor la- values ton assess effect of anticoa0ulant therap! and report la- values outside the desired ran0e. La- values reflect pro0ress of the patient4s venous flow and peripheral tissue perfusion. (5B/5ct) (Potter Perr!" #$$%" p. &'() Reduces tissue swellin0 and rapidl! e+pties superficial and ti-ial veins" preventin0 overdistention and there-! increasin0 venous return (Potter Perr!" #$$%" p. &'() *wellin0 or lac3 of swellin0 indicates whether venous flow is efficient. (Potter Perr!" #$$%" p. &'%) Palpation of pedal pulses indicates venous flow throu0hout RLE. (Potter Perr!" #$$%" p. &'%)

,oal 1et2 Patient4s PTT" PT" I/R" 56T/5B levels were within nor+al ran0es.

*hort Ter+ ,oal Ineffective tissue B! the end of shift" patient perfusion R/T will de+onstrate increased interruption of venous perfusion AEB la- results flow AEB DVT located ./L. on the RLE. Lon0 Ter+ ,oal (Potter Perr!" #$$%" En0a0e in -ehaviors or p. &'() actions to enhance tissue perfusion.

Elevate le0s when pt is on -edrest.

,oal /ot 1et2 Patient had a hard ti+e elevatin0 his le0s when l!in0 in -ed. 5e co+plained of increased pain when le0s were elevated for +ore than a few +inutes. ,oal 1et2 There was no tenderness or swellin0 present on the lower e7tre+ities.

6hec3 for swellin0 in RLE ever! # hrs.

6hec3 pedal pulses ever! # hrs.

,oal 1et2 Pedal pulses were present at ever! chec3up.

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