Subjective Objective Diagnosis Planning Intervention Rationale Evaluation

Vital Signs taken as Ineffective After 8 hours  Establish  To assess Goal met,
 Chest pain follows: breathing of nursing rapport precipitatin after 8 hours
 Fatigue Temp: 37.2 pattern related intervention, g and of nursing
and RR: 31 cpm to fatigue and patient will causative intervention,
weakness PR: 102 bpm chest pain. be able to:  Monitor the factors patient will
BP: 130/80 vital  To obtain be able to:
O2 saturation: 93%  Establish a signs. baseline
normal, data  Establish a
Patient manifested: effective normal,
 Monitor and
 Hypertension respiratory manage  Keeping effective
pattern. blood blood sugar respiratory
 Initiate sugar. in the pattern.
needed optimal  Initiate
lifestyle range if a needed
changes. diabetic can lifestyle
 Relieve chest help reduce changes.
pain.  Assess the stress  Relieve chest
patient on the pain.
appetite kidneys.
 To prevent
 Monitor fluid
Intake & overload
Output
 Monitor
kidney
functions
and
calculate
fluid
retention.
Daily
weights at
the same
time each
 Check urine day on the
bag as same scale
appropriate can also
help
determine
 the amount
 Provide of fluid
medication being
as retained.
prescribed
 To help
monitor
fluid
balance and
characterist
ics of
urine.

 Promote
healing.

Subjective Objective Diagnosis Planning Intervention Rationale Evaluation

Vital Signs taken as Decreased  Show stable  Establish  To assess Goal met,
 Chest pain follows: Cardiac Output cardiac rapport precipitating Patient
 Fatigue Temp: 37.2 rhythm and and causative demonstrates
and RR: 31 cpm rate. factors adequate cardiac
weakness PR: 102 bpm  Patient  Monitor the  To obtain output as
BP: 130/80 demonstrates vital signs. baseline data evidenced by
O2 saturation: 93% adequate blood pressure
cardiac and pulse rate
 To know the
Patient manifested: output as and rhythm
abnormal
 Hypertension evidenced by within normal
 Check findings.
blood parameters for
patient’s lab patient; strong
pressure and data (cardiac
pulse rate peripheral
markers, blood pulses; and an
and rhythm cell count,
within normal ability to
electrolytes, tolerate
parameters ABGs, etc.) to
for patient; activity without
determine symptoms of
strong contributing
peripheral dyspnea,
factors. syncope, or
pulses; and  Auscultation  Compensatory
an ability to chest pain.
of breath tachycardia is
tolerate sounds and a common
activity heart rhythm. response for
without Observe patients with
 symptoms of patient’s skin significantly
dyspnea, color, low blood
syncope, or temperature, pressure to
chest pain. and capillary reduce cardiac
 refill time. output.
Initially,
this
compensatory
response has a
favorable
effect on
cardiac output
but can be
harmful when
it becomes
 Administer persistent.
medication as  Manage the
prescribed. disease.

Subjective Objective Diagnosis Planning Intervention Rationale Evaluation

Vital Signs taken as Decreased   Establish  To assess Goal met,
 Chest pain follows: Cardiac Output rapport precipitating Patient
 Fatigue Temp: 37.2 and causative demonstrates
and RR: 31 cpm factors adequate cardiac
weakness PR: 102 bpm  Monitor the  To obtain output as
BP: 130/80 vital signs. baseline data evidenced by
O2 saturation: 93% blood pressure
and pulse rate
 To know the
Patient manifested: and rhythm
abnormal
 Hypertension within normal
 Check findings.
parameters for
patient’s lab patient; strong
data (cardiac
 peripheral
markers, blood pulses; and an
cell count, ability to
electrolytes, tolerate
ABGs, etc.) to activity without
determine symptoms of
contributing dyspnea,
factors.  Compensatory syncope, or
 Auscultation tachycardia is chest pain.
of breath a common
sounds and response for
heart rhythm. patients with
Observe significantly
patient’s skin low blood
color, pressure to
temperature, reduce cardiac
and capillary output.
refill time. Initially,
this
compensatory
response has a
favorable
effect on
cardiac output
but can be
harmful when
it becomes
persistent.
 Administer  Manage the
medication as disease.
prescribed.