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ASSESSMENT EXPLANATION OF OBJECTIVES NURSING RATIONALE EVALUA

THE PROBLEM INTERVENTIONS TION
Subjective: Normally, there is STO: within 2 Diagnostic Fully met:
“Magpapacheck- significant increase in hours of 1.) Assessed vital signs (BP, 1.) To determine the Patient’s
up lang sana ako, blood pressure among nursing HR) effectiveness of BP:
kaso nahilo at pregnant women interventions, intervention. 130/90,
tumaas BP ko” during their course of client will have 2.) Assessed peripheral 2.) To identify possible absence of
pregnancy period. BP of less than extremities presence edema, dizziness
It is a response of the or equal to varicosities or swelling. and
Objective: body to the increase in 130/90mmHg, tingling
Vital signs: blood volume. absence of Therapeutic sensation
BP: However, it becomes dizziness and 1.) Administered 1.) To reduce blood fluid on both
150/100mmHg fatal if not monitored tingling magnesium sulfate via volume by means of hands.
CR: 102 bpm regularly. sensation on solu-set increasing urine output.
SpO2: 94% both hands 2.) To meet oxygen demand
RR: 20 cpm Due to the increased 2.) Given low flow oxygen by the increased heart
blood pressure, there (1-2 lpm) via nasal rate.
cannula 3.) To allow full lung
No signs of edema is a decreased cardiac
3.) Positioned to semi- expansion and allows
on extremities due to increase in
fowlers. more air to enter the
Not distended heart rate resulting to
lungs
jugular vein inadequate blood
No signs of pumped by the heart.
4.) Provided warm blanket 4.) To provide warmth.
paleness
Capillary refill and Decreased cardiac
skin turgor less output is defined as Educative
1.) Taught deep breathing 1.) To reduce stimuli and
than 1 second inadequate blood
exercises produce calming effect
With pulse grade pumped by the heart
reducing BP
of +2 to meet the metabolic
2.) Emphasized importance 2.) Lessens physical stress
With tingling demands of the body.
of adequate rest and and tension that affect
sensation on both
limit strenuous activities increase in blood
hands pressure
Not in respiratory References
distress. Doenges, M., 3.) To increase venous
3.) Instructed to ambulate
Moorhouse, M., & return.
feet regularly
Nursing Murr, A. (2009).
Diagnosis Nurse's pocket guide. 4.) Instructed to report
Decreased cardiac Philadelphia: Davis dizziness and difficulty 4.) To provide proper
output related to Company. in breathing. medical and nursing
increased heart management as needed.

ASSESSMENT EXPLANATION OF OBJECTIVE NURSING RATIONALE EVALUAT THE PROBLEM S INTERVENTIONS ION .rate.

manifested by (with permission).) Awareness of the hospitalization the environment and environment promotes new experiences or comfort and may people as needed.) Familiarize patient with 3. A.) Promotes relaxation Nursing exercises and provided Diagnosis calm environment Anxiety related to 3.Subjective: It is normal for a STO: after 30 Diagnostic Fully met: “Kinakabahan kasi person to get anxious mins of 1. signs 2. touch 1. clarification of needs. anxious feeling can help the RR: 20 cpm Murr. (2009). M. her son to come see patient.) Being supportive and face. hospitalization.) To determine Patient was ako lagi kapag during clinical nursing contributing to anxiety appropriate able to nagpapacheck-up” consultation or check. 2. and possible 130/90mmHg sometimes reduces vital signs Shaky hands And CR: < 100 anxiety. Hg. unknowns. intervention interventions and relax as up.) Talking about anxiety. approachable promotes to interact holding and reason was the result calm face and verbalization. and communication clearly.. expressing feelings hands.) Taught deep breathing 2. realistically and recognize Philadelphia: Davis factors leading Company.) Encourage expression or 1. CR: CR: 102 bpm Doenges.) Diverted patient 2. of BP: Vital signs: References: bpm Educative 130/90mm BP: 150/100mmHg 1.) Talking or otherwise non-shaky her as soon as BP: =< attention. producing situations and <100 bpm SpO2: 94% Moorhouse.) Assessed stressors 1. rubbing both may not desirable or non-shaky demeanor to remind understand hands. decrease anxiety experienced by the patient. & concerns. In the case of our patient will be evaluate degree of manifested patient.) Use presence. she gets in a relaxed Therapeutic anxiety by calm Objective: anxious every time she state as 1. M. Anxiety may intensify to a panic level if patient feels threatened and unable to control environmental stimuli. not as she expected as hands with patients that they are s the Noted to be texting claimed by the stable vital not alone and to situation . . able Observed to goes for a check-up. and questions about patient perceive the situation Nurse's pocket guide..