NURSING INTERVENTION 1. Place patient on semiFowlers position.
SUBJECTIVE: ³ OBJECTIVE: Bradycardia (HR ± 54) Weak pulse Decreased BP (80/ 60)
Decreased cardiac output related to altered heart rhythm as manifested by decreased heart rate.
Constriction of Within 8 hours coronary artery of nursing intervention, the patient will Decreased display blood flow to hemodynamic the heart stability as evidenced by: Decreased effectiveness of heart as a pump a. BP: 100140/ 80120 b. HR = 60 ± 100 bpm Decreased pulse rate
1. To aid in maximal lung expansion and promote comfort on the patient. 2. To decrease 2. Advise oxygen patient to limit consumption movement. by the cells 3. Monitor VS frequently (every hour). 4. Administer oxygen therapy as ordered. 3. To note patients responses to interventions. 4. To increase oxygen available for perfusion. 5. To manage increase oxygen consumption in state of increased metabolic rate (fever).
After 8 hours of nursing intervention, the goal was partially met as evidenced by: a. BP: 100/ 60 b. HR: 61
Decreased BP 5. Administer antipyretics PRN.
To aid in coronary perfusion. 7.
.6. Administer vasodilators as ordered
To clearly understand the situation in order to formulate an appropriate approach
4. To know the degree of impairment in functioning. di tulad nung kabataan ko´ as verbalized by the patient. Expressed feelings of improved decision making
Age (66 y/o)
1. Guide patient 4. Encourage 2.
Within 8 hours of nursing intervention. To identify verbalization what is the of concerns. OBJECTIVE: Delayed decision making
Decisional conflict related to extreme age as manifested by delayed decision making. yung decision making ko mabagal. 3. Expression of feeling of improved decision making
SUBJECTIVE: ³Minsan parang nahihirapan ako magdesisyon. To help in problemthem realize solving the positive process by and
. Declining brain the patient will functioning be able to express concerns Poor decision regarding making decisionmaking as evidenced by: a. the goal was completely met as evidenced by: a.
After 8 hours of nursing intervention. specific problem that needs problemsolving.CUES
NURSING INTERVENTION 1. Assess for physical signs of distress. Help the patient to review information about past decision.
negative aspect of every choices. 5. To aid in better decision making.
5. Provide factual information about the problem.providing choices.