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ASSESSMENT EXPLANATION OF GOALS OF CARE NURSING RATIONALE EVALUATION

THE PROBLEM INTERVENTION
Subjective Decrease cardiac Long Term Long Term
“Ang sakit sakit output there is an Objective Monitor and To obtain Objective
ng ulo ko, hindi inadequate blood After 72 hours of record Vital Signs baseline data Fully met if
ako makahinga” pumped by the nursing
“Tae ako n tae heart to meet the intervention the Note skin color, Skin pallor, or Partially met if
halos 5 days na metabolic patient will have and feel the mottling, cool or
minsan may demands of the DKO ALAM TO temperature of cold skin Not met if
kasama siyang body. There is the the skin temperature, or
dugo as suka ako need enough red Short Term an absent pulse Short Term
ng suka. Ta blood cells and Objective can signal arterial Objective
feeling ko lagi water in the After 8 hours of obstruction, Fully met if
akong uhaw. “ blood for the nursing which is an Partially met if
heart to push the intervention the emergency that Not met if
“Minsan hindi fluids around patient the requires
parang within the blood patient will have immediate PAKILAGAY NLG
nacoconfuse siya vessels. In the Assess Jugular intervention INAANTOK NA ME
 Good skin
kung asan siya”. case of the Vein Distention
turgor.
Stated by patient, she was Jugular venous
 Good
daughter experiencing pressure is low in
peripheral hypovolemic
severe diarrhea,
perfusion shock;
Objective vomiting and
(acral warm, it increases with
With cld and fluid loss, when
dry and red) effective treatment
clammy the body
 Normal Vital and is significantly
extremities becomes increased
Signs
With capillart dehydrated, with fluid overload
refill of 1-3 there may be PAKICHECK NOT Review Hgb and and heart failure.
seconds enough red blood SURE TO Hct levels and
With rapid weak cells, but the note trends
pulse total volume of Decreased RBCs

RR:20 inadequate. minute. Position patient lead to severe easy fatiguability Water makes up to Modified dehydration. and region Cardiac Output fluid losses it the head is related to increases the slightly elevated __________(NOT body's ) . If water is (The lower urine and body BP: 80/30 lost or fluid extremities are weight HR:45bpm intake is elevated to an decreased. With Vital Signs about 90% of Trendeleburg concentrated of: blood. the angle of about 20 T: 35.Skin is noted to fluid is decreased can adversely be pale with poor that leads to the affect oxygen skin turgor. But as the horizontal. determine if the Observed Cardiac output is Record the input patient needs to experiencing the amount of and output. the vomiting. the Increases blood Urine output: 20 maintain cardiac knees are circulation and ml/hr output by making straight. is weak with heart speeds up diarrhea. narrowed focus to try to keep its diaphoresis) can and complains of output steady. diuresis. reduces pressure the heart beat the trunk is on the pelvic Decreased faster.3 body tries to degrees. pressure within carrying Lips appered the system capacity.This will slightly blue decreases. If there lightheadedness is less blood in Losing a lot of and headaches the system to be fluids (through Observed patient pumped. urine undergoe Blodd excessive blood that the specific gravity Transfusion sweating heart can pump record Therapy Complaints of out in one extreme thirst.

volumedeficit.V. Tight clothing can constrict Begin an I. breathing. large bore (16 to Start Blood 18 gauge) Transfusion cannula for therapy as per intravenous lines physician’s order was used to replace volume rapidly .Isot onic saline willrapidly expandextracellul ar fluid volume. further infusion with reducing the normal saline amount of solution or oxygen carried to lactated Ringer’s the brain solution delivered Initial goal is to through a large correctcirculatory bore.SURE) compensation a mechanisms which can lead to Loosen Tight decrease in BP Clothing and HR with decreased urine output can result to shock.

Hypovolaemia occurs as a result of blood loss due Administer to trauma or Oxygen as occurs peri- ordered operatively. at the not occur same time and on the same scale with patient To increase the wearing the amount of same amount of oxygen carried by clothing available hemoglobin in the blood To evaluate fluid Maintain balance. then packed red blood cells should be replaced to ensure that Weigh the patient hypoxaemia does daily. physic al rest a n d emotional rest by providingquiet and relaxedenvironm en .

PAKIDAGDAGAN to reduce oxygen NLG IF EVER demand and toprevent increasing cardiac deman .