ASSESSMENT DIAGNOSIS PLANNING INTERVENTIO RATIONALE EVALUATION

N
Subjective: Ineffective Short term Independent: Short term
“Parang wala tissue goal: goal:
na ako perfusion • Monitored - To establish
maramdaman related to After 30 vital signs baseline data After 30
sa mga kamay decrease minutes of minutes of
at paa ko” as cardiac output rendering • Monitored - To determine rendering
verbalized by secondary to nursing input and fluid volume nursing
the patient burn shock as intervention, output relative to oxygen intervention
evidence by the patient will transportation the goal was
Objective: weak be able to: and circulation met as
•(+) Eschar peripheral evidenced by:
• Laboured pulses - Verbalize • Checked for -Dysrhythmias can
breathing understanding irregular pulses occur as a result - The patient
• Cold of condition of electrolyte verbalized
clammy skin and therapy shifts, electrical understanding
on unburned regimen injury of condition
area and therapy
• Skin color • Incorporated - Indicators of regimen
red to brown importance of decreased
• Irritable reporting deep perfusion
• (+1) throbbing pain,
Peripheral numbness
pulse
• Vital signs • Assessed - Edema
as follows: color of the formation readily
skin, compresses blood
BP: 130/90 Long term movement of vessels thereby Long term
RR: 22cpm goal: the upper and impending goal:
PR: 110bpm lower circulation and
SpO2: 93% After a week of extremities increased edema After a week of
hospitalization, and peripheral hospitalization,
the patient will pulses and goal was met
be able to capillary refill as evidenced
demonstrate by:
increased •Capillary refill -Used to monitor
perfusion as measured dehydration and - Absence of
evidenced by: amount of blood edema
flow to tissue
- Vital signs
• Encouraged - Promotes within normal
active ROM systemic range:
 exercise on circulation/venous
unaffected return
part of the PR:80bpm
- Absence of body RR:20cpm
edema BP:
- Vital signs - Maximizes 120/80mmHG
within normal • Elevated the circulating volume SpO2: 99%
range: affected and systemic
extremities circulation
PR:60-100bpm
RR:12-20cpm
BP:
120/80mmHg
Dependent:
• Administer - Relieves pain
pain and reduce
medications as discomfort
prescribed by
the physician

• Administer IV
fluids as -Maintain fluid
ordered replacement and
to improve tissue
perfusion

• Administered
supplemental - Oxygen increases
oxygen arterial saturation