Assessment Nursing Planning Nursing Intervention and Evaluation

Diagnosis Rationale

Subjective: Ineffective tissue After 8 hours of nursing Independent Goal partially met. The
“ Medyo nahihilo ako perfusion r/t intervention the patient will Establish rapport patient manifested
at masakit ang batok vasoconstriction of be able to manifest increase >to gain trust and participation of the improvement as evidence
ko”, as verbalized by blood vessels tissue perfusion as evidence patient in the treatment process by BP of 130/90 and
the patient by: feeling of relieved
Monitor and record vital signs irritability mood
BP within normal range >to obtain baseline data
Objective:
>Edema noted in the Edema subsides Provide quiet and restful
extremities, grade 3 environment
Relieve irritability mood >decrease the demand for oxygen
>BP of 140/90
Dependent
>Irritablity Administer anti-hypertensive as
ordered.
>dizziness >Anti- hypertensives helps to
decrease and control blood pressure