Professional Documents
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SILLIMAN UNIVERSITY
CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: Ineffective tissue perfusion At the end of our two-day Monitor vital signs and laboratory Serves as baseline data At the end of our two-day
related to decreased albumin care, the client will results and to determine for care, the client did not
Verbalized that the concentration in the blood manifest increased tissue any abnormalities manifest increased tissue
edema on her left hand perfusion as evidenced perfusion as evidenced by:
and lower extremities by:
occurred when she has Assess skin temperature, turgor, To determine presence Goal met. Vital signs are
regained consciousness Vital signs within normal and integrity of edema or any within normal range
(date unable to recall) range abnormalities except blood pressure
after surgery as BP= 100-140/ 60-90
verbalized by the T= 36.5- 37.5◦C Temperature: 36.7- 37C
husband P= 60-100bpm Monitor IVF infusion rate, and the To asses for Pulse rate: 76- 80 bpm;
R= 15-20cpm IV site overinfusion/ strong and regular
Verbalized feeling of underinfusion or any Respiratory rate: 27
heaviness in the left other complications cpm, regular, quiet and
hand and lower effortless; taken twice
extremities Blood pressure: 130/90
Measure circumference of Useful in identifying mmHg; taken twice
extremities, as indicated edema involved in the
Objective: extremities
No presence of edema in Goal partially met. Edema
Presence of edema in the IV site and lower is still present in the
the IV site which is the extremities Assess presence of neck To determine for any lower extremities and in
left hand distention/ hepatojugular reflux other complications the IV site
Vital signs:
Will demonstrate Apply warm compress To increase circulation Goal met. used
Temperature: 37.1 nonpharmacalogic of the affected area, nonpharmacalogic
C; taken twice methods and activities thus, reducing edema methods and activities to
Pulse rate: 68-78 to improve circulation improve circulation such
bpm; strong and such as application of as application of warm
regular warm compress and Encourage to eat food rich in To help in the compress and ambulation
Respiratory rate: ambulation and deep iron such as liver, and production of iron in and deep breathing
28 cpm, regular, breathing exercise vegetables the blood , thus exercise