BAP

CUES NURSING NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVE INTERVENTION
Subjective: Ineffective Breathing After 8 hours of - Establish - To gain the •After how many
“Jak makaanges nga pattern related to nursing intervention. Rapport trust of the hours of nursing
nasyaat ading” as shortness of breath The patient will - Monitor Vital patient intervention the client
verbalized by the possible evidence by display blood signs - Indicators of will be able to
patient. cues. pressure within her - Assess the adequacy of verbalize decrease of
normal range patients systematic pain from 8/10 to
Objective: physical perfusion, 3/10
- Restlessness condition fluid/blood, •Clients blood
- Weak looking - Observe non- needs, and pressure is below
- Shallow verbal cues of developing 160/100mmHg
breathing pain such as complications •After how many
Vital Signs: holds body, - To determine hours of nursing
BP: 160/100 facial the severity of intervention the client
PR: 89 expression the pain will able to report
RR: 20 - Assist patient - Supported absence of pain.
TEMP: 36.7 to patient to
comfortable comfortable
position, such position such
as supporting as high
upper fowler’s
extremities position.
with pillows.
BAP

CUES NURSING NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVE INTERVENTION
S: Patient reports of Risk for decreased After 4 hours of -Measure BP in both -Serial measurements After 4 hours of
cold clammy skin, Cardiac Output as nursing intervention arms. Take three using correct nursing intervention
chills and dizziness. evidenced by altered the patient will readings, 3 to 5 equipment the patient
O: afterload. demonstrate stable minutes apart while provide a more demonstrates stable
BP: 200/120 mmHg cardiac rhythm, rate the client is at rest, complete cardiac rhythm, rate
PR: 112 bpm and BP within normal then sitting, and then picture of vascular and BP within normal
TEMP: 37.1*C range of 120/80 standing for initial involvement and range of 120/80.
O2SAT: 96% evaluation. Use scope of
correct cuff size and problem. Progressive
accurate technique. diastolic readings
Take note of above
elevations in systolic 120 mm Hg are
as well as diastolic considered
readings. first accelerated, then
malignant (very
-Observe skin color, severe).
moisture, Systolic hypertension
temperature, and also
capillary refill time. is an established risk
factor
-Observe for for cerebrovascular
dependent and disease and ischemic
generalized edema. heart
self-care activities as disease even when
needed. diastolic pressure is
not
-Provide calm, restful elevated. In younger
surroundings, clients
minimize with normal systolic
environmental readings, elevated
activity and noise. diastolic
Consider limiting the numbers may
number of visitors or indicate
BAP

length of visitation. prehypertension.

-Maintain activity -Presence of pallor;

restrictions (such as cool, moist skin; and
bedrest or chair rest) delayed capillary
during crisis refill time may be
situations and due
schedule periods of to peripheral
uninterrupted rest; vasoconstriction or
assist client with reflect cardiac
self-care activities as decompensation and
needed. decreased output.

-Provide comfort -May indicate onset

measures, such as of heart or kidney
back and neck failure.
massage or elevation
of head. -Helps reduce
sympathetic
-Instruct in relaxation stimulation and
techniques, guided promotes relaxation.
imagery, and
distractions, if the -Reduces physical
client is interested stress and tension that
and able to affect BP and the
participate. course of
-Monitor response to hypertension.
medications that
control BP. -Decreases
discomfort and may
COLLABORATIVE: reduce sympathetic
Administered stimulation.
medications as
ordered. -Can reduce stressful
stimuli and produce a
calming effect,
BAP

thereby reducing BP.

CUES NURSING NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVE INTERVENTION
- Blood glucose Risk for unstable SHORT TERM: INDEPENDENT: ● Hypertension is The Client verbalized
level of glucose The Client will ● Report BP of commonly associated self-care actions to
269mg/dL level related to verbalize more than 160 with diabetes. Control take if blood glucose
- Inadequate adherence self-care actions to mm Hg of is too high or too low
blood glucose of diabetes take if (systolic). BP prevents coronary a week from the date
medication management blood glucose is too Administer artery disease, stroke, of care.
management plan as evidenced by high hypertensive as retinopathy, and LONG TERM:
- Inadequate inadequate blood or too low a week prescribed. nephropathy. The client maintained
glucose glucose and blood from the ● Assess for signs ● Hyperglycemia fasting blood glucose
monitoring glucose date of care. of results level of 105 mg/dL, 1
level of 269mg/dL LONG TERM: hyperglycemia when there is an hour after the meal a
The client will ● Assess inadequate amount of level of 155 mg/dL,
maintain medications insulin to glucose. and 2 hour pc level of
fasting blood glucose taken regularly. Excess 130 mg/dL
level ● Monitor blood glucose in the blood goals during
of 105 mg/dL, 1 hour glucose levels as creates an osmotic each patient
BAP

after fasting and effect visit.

the meal a level of postprandial that results in increased
155 levels. thirst (polydipsia),
mg/dL, and 2 hour pc ● Assess feet for hunger
level temperature, (polyphagia), and
of 130 mg/dL pulses, color, increased urination
and sensation. (polyuria). The patient
● Assist the may also report
patient in nonspecific symptoms
identifying of
eating patterns fatigue and blurred
that need to be vision.
modified. ● A lot of drugs can
● Review the cause
progress toward fluctuations in blood
DEPENDENT: glucose as a side effect.
● Administer basal Beta-blockers,
and prandial corticosteroids, thiazide
insulin, as diuretics, estrogen,
ordered by the isoniazid, lithium, and
physician. phenytoin can cause
COLLABORATION: hyperglycemia. Regular
● Refer to a use of salicylates,
registered disopyramide, insulin,
dietitian for sulfonylurea agents,
individualized and
diet instruction pentamidine can cause
hypoglycemia.

Normal fasting blood

glucose for an adult is
70
to 105 mg/dL. Critical
values for
hypoglycemia
are less than 40 to 50
BAP

mg/dL. Critical values

for
hyperglycemia are
greater
than 400 mg/dL.
● This is to monitor
peripheral perfusion
and
neuropathy.
● This information
provides
the basis for
individualized dietary
instruction related to
the
clinical condition that
contributes to
fluctuation
in blood glucose levels.
● Patient involvement
in the
treatment plan
enhances
adherence to treatment
plan
● Adherence to the
therapeutic regimen
promotes tissue
perfusion.
Keeping glucose in the
normal range slows
progression of
microvascular disease.
DEPENDENT:
● An individualized
meal
BAP

plan depends on the

patient’s body, weight,
blood glucose values,
activity patterns, and
specific clinical
condition.
Modifications in the
patient’s food intake
will
contribute stabilization
of
blood glucose levels.
COLLABORATION:
● Specific exercises
can be
prescribed based on
any
physical limitations the
patient may have.