ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective Ineffective After 8 hrs independent After 8 hrs of
tissue of nursing intervention
perfusion intervention goal was met
Objective related to Mr TMG -monitor -to note the with vital
decreased will cardiac rhythm effectiveness of signs of bp
-BP 140/90 cardiac maintain BP continuously medication 128/82,RR
-T 36.9 output as stability 18,HR
-HR 92BPM manifested within -monitor vital 76 ,SpO2 96,
increase normal -to monitor T 37.1 no
-RR 32 BPM signs every 1-2
blood range and baseline data chest pain
-restlessness hours and PRN
-chest pain pressure of participate and
-shortness of 140/90 in activities -increase shortness of
breath activity levels breath. And
-pale skin gradually as can now
SpO2-90% permitted by participate in
individual activities like
condition, exercise.
noting v/s
response to
activity

-this provides a
baseline for
-evaluate comparison to
reports of and follow trends
evidence of and evaluate
extreme response to
fatigue, interventions
intolerance for
activity and
progressive
shortness of -To reduce blood
breath. pressure and
prevent
-provide diet cardiovascular
restriction e.g diseases
low fat, low
sodium
-to reduce
anxiety and
conserve energy
-encourage function/tissue
relaxation perfusion
technique

-to allow for

timely alteration
-monitor urine in therapeutic
output hourly regimen
or periodically
weigh daily
noting total
fluid balanc
-to increase
Independent oxygen available
for cardiac
- Administer functions/tissue
oxygen via perfusion
mask or
ventilator as -to support
indicated. systemic and
cardiac
-administer IV circulation
as indicaterd
nitroglycerin
(3) doses of
sublingual,
Morphine 5
mg
intravenous
push (IVP), 324
mg
chewable baby -to
aspirin. determine/adjust
individually
Collaborative appropriate diet
plan
Arrange time
to the
nutritionist
/dietician

-refer to
cardiac
rehabilitation
program as
indicated