NURSING SCIENTIFIC GOAL OF NURSING

DATE CUES RATIONALE EVALUATION

DIAGNOSIS BASIS CARE INTERVENTION

March ROS Ineffective Definition Of After 3 INDEPENDENT INDEPENDENT After 3 days of

17, - The patient Tissue The Nursing days of nurse- patient
- Encourage - Exercise
2021 was reported Perfusion Dx nurse- interaction, the
to have the patient to helps increase
related to patient patient was be
vaginal walk with a venous return,
Excessive It is defined interacti able to:
bleeding, support hose build up
blood loss as the on, the
severe on and perform collateral - engage in
secondary decrease in patient circulation, and
abdominal toe up and behaviors or
to oxygen, will be point flex strengthen the
pain and resulting in actions to
premature able to: exercises. calf muscle
rapid uterine improve tissue
placental failure to pumps.
contractions, - perfusion.
separation nourish
occurred 3 engage - Maintain - This ensures
hours prior to tissues at - maintain
capillary in optimal cardiac adequate
her output. maximum
level. behavio perfusion of
admission. vital organs. tissue perfusion
rs or
to vital organs,
- Experiences Pathophysiol actions - Monitor - These are as evidenced
continuous ogical Basis to peripheral symptoms of by present and
pain on the improve pulses. Check arterial strong
lower part of Insufficient tissue for loss of obstruction peripheral
her abdomen. arterial blood perfusio pulses with that can result pulses, vitals
flow causes n. bluish, purple, in loss of a
- Patient feels or black areas within patient’s
decreased limb if not
a sharp or - and extreme normal range
nutrition and immediately
stabbing pain maintai pain. and normal
oxygenation reversed.
and cramping n ABG’s.
at the cellular
whenever her maximu - Provide - This
level.
aches. m oxygen therapy saturates
Decreased
tissue as necessary. circulating
tissue
- Patient was perfusio hemoglobin
perfusion can
reported n to and augments
be the efficiency
having back vital
temporary, of blood that is
pains, organs,
with few or reaching the
headaches, as
minimal ischemic
dizziness, evidenc - Encourage
consequence tissues.
and blurry ed by smoking
s to the
vision. present cessation. - Smoking
health of the
and tobacco is also
- Patient patient, or it
strong associated
experienced can be more
periphe with
back pain acute or
ral catecholamine
and protracted, s release
pulses,
abdominal with resulting in
vitals
potentially
wall destructive within vasoconstrictio
weakness effects on the patient’ n and
and physical patient. s ineffective
- Provide
movement is normal tissue
knowledge on
limited Rationale range perfusion.
normal tissue
because of The oxygen and perfusion and - Knowledge of
lower back being normal possible causative
pain and supplied in ABG’s. causes of factors
hypertension. the body is impairment. provides a
not enough rationale for
- The pain due to DEPENDENT
treatments.
and the excessive
- Check for
bleeding blood loss
optimal fluid DEPENDENT
hinder her which is
balance.
from getting responsible Administer IV - Sufficient
adequate for the fluids as fluid intake
sleep. oxygenation ordered. maintains
of the tissues adequate filling
Assessment thus leading pressures and
- Blood to ineffective optimizes
pressure: tissue cardiac output
140/90 perfusion. needed for
mmHg - Administer tissue
- medications as perfusion.
Cardiovascul prescribed to
treat underlying - These
ar - 1000 mL
problems. Note medications
of blood loss
the response. facilitate
after C- perfusion for
section was most causes of
observed impairment.
- Uterus -
moderate to
excessive
bleeding is
present.

Diagnostic
Studies

Complete
Blood Count

- WBC 12.4
K/uL
- Hgb 12.8
g/dL
- Hct 37.3%
- Platelet 120
K/uL

Urine
Analysis

- WBC - 12.4
u/L
-
Transparency
- Foamy/
Cloudy