ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
August 13, 2019 Activity Within 8 hrs. INDEPENDENT: Goal partially
Intolerance span of 1. Established - To gain met.
related to body care, the rapport. the trust  After 8
SUBJECTIVE CUES: weakness as patient will of the hours span
evidenced by be able to patient of care
report
“Luya pa akong lawas ma’am”as verbal report of and patient was
measurable
patient verbalized fatigue and increase significant report a
weaknesses energy and others measurable
will increase in
2. Assessed
OBJECTIVE CUES: participate in -To activity
response to
necessary identify tolerance.
activity including
-Body Weaknesses desired causative
activities. pre/post v/s.
-Fatigue Background factors
-BP: 160/90 Study:
3. Provided patient
-To assist
with positive
Insufficient pt. to deal
atmosphere
physiological with
energy to manage
endure or factors
complete that
required of contribute
desired daily to fatigue
activities
4. Encouraged
-To
patient
provide
participation in
pt. with a
planning
sense of
activities
control

5. Assisted pt. in
carrying out
 self-care -To
activities improve
mobility
6. Encouraged pt.
to carry out
-To
ADL’s
enhance
motivation
7. Placed pt. on a
position of -To
comfort maintain
body
alignment
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
August 13, 2019 Decreased Within 8 hours INDEPENDENT: Goal partially met.
cardiac output span of care 1. Established - To gain trust After 8 hrs. span
SUBJECTIVE related to patient will have Rapport of care patient still
CUE: no elevation in 2. Vital signs - To have has elevation of
blood pressure taken and baseline data blood pressure
“Taas jud ko ug above normal recorded above normal
BP ma’am, limits and will 3. Assessed limits.
- To monitor for
maong malipong maintain blood radial pulse
arrhythmias;
ko usahay” as pressure within every hrs. and
impending
patient verbalized. acceptable limits. reported and
cardiac arrest
Background deviation from
OBJECTIVE Study: the baseline
CUES: 4. Reduced - To help
Inadequate blood stressful decrease
-BP: 160/90 pumped by the elements, such arrhythmias
heart to meet the as excessive
metabolic noise in the
demands of the patient’s
body. environment
5. Provided
dietary -To reduce risk of
6. Change pt’s cardiac disease
positioning -It is drug indicated
frequently for hypertension
7. Observed skin
color,
temperature, -Peripheral
vasoconstriction
capillary refill
may result in pale,
time and cool, clammy skin
diaphoresis with prolonged
capillary refill time
 due to cardiac
DEPENDENT: dysfunction and
decreased cardiac
output
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
August 13, 2019 Within 8 hours INDEPENDENT: Goal Partially
Deficient span of care met.
SUBJECTIVE Knowledge patient will be -Established -To gain trust After 8 hours
CUE: related to able to verbalize Rapport span of care the
understanding of -Assessed -Misconceptions patient verbalized
disease process readiness and and denial of the the disease
blocks to learning. diagnosis because
OBJECTIVE and treatment process and
Include significant of long-standing
CUES: regimen treatment
other(SO) feelings of well-
being may interfere regimen
BACKGROUND with patient and SO
STUDY: willingness to learn
about disease,
Absence or progression and
deficiency of prognosis
cognitive -Defined and state -Provides basis
information the limits of desired for understanding
related to specific BP. Explain elevations of BP
hypertension and and clarifies
topic
its effects on the frequently used
heart, blood
medical
vessels, kidneys
and brain technology

-Assisted patient -These risk

on identifying factors have been
modifiable risk shown to
factors contribute to
hypertension and
cardiovascular
and renal disease
-Problem-solve with -Changing
patient to identify “comfortable or
ways in which usual” behavior
appropriate lifestyle patterns can be
changes can be very difficult and
made to reduce
stressful.
modifiable risk
factors Support,
guidance and
empathy can
enhance pt’s
success in
accomplishing
these task
-Monitoring BP at
home is
-Instructed and reassuring to pt.
demonstrated
because it
technique of BP
self-monitoring. provides visual
Evaluated patients and positive
having visual reinforcement for
acuity, manual efforts in following
dexterity and the medical
coordination regimen and
promotes early
detection and
deleterious
changes.
 ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
OBJECTIVE Risk for injury Within 8 INDEPENDENT: Goal Partially
CUES: hours span of met.
 Age: 62 y/o care patient 1. VS taken and - To have baseline After 8 hours
 BP: will be able to recorded. data span of care
160/90mmHg be free from 2. Encouraged to do - To prevent patient was
 Needs BACKGROUND injury. handwashing at all nosocomial free from injury.
assistance STUDY: times, and device infections and
when going to Vulnerable to safety when potential for
bathroom physical damage patient has IV blood borne
due to lines. pathogens
environmental
conditions 3. Raised bed side - To prevent injury
interacting with rails. to both patient
the individual’s and care
adaptive and providers
defensive 4. Identified - To promote safe
resources, which interventions and physical
may compromise safety devices. environment and
health. individual safety

5. Encouraged - To prevent injury.

significant others
to assist patient
when going to
bathroom.