ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Ineffective Tissue Short Term Independent Independent Short Term

Perfusion related
“ Medyo to blood clots After 8 hours of  Assess presence, location, It is useful in identifying After 8 hours of Nursing
nakakaramdam ako Nursing Intervention and degree of edema or quantifying edema in Intervention the patient is
ng pamamaga ng the patient will be formation the involved extremity able to demonstrate
kamay ko“ as able to demonstrate  Measure capillary refill increased perfusion as
verbalized by the increased perfusion  Determine the pulse to determine adequacy individually appropriate
patient as individually equality, as well as the of systemic circulation
appropriate intensity (ex. bounding, Long Term
Objective normal, diminished or to evaluate distribution
Long Term absent) and compare with and quality of blood flow After a week of Nursing
Pulmonary edema unaffected extremity and success of therapy Intervention the patient is
HR- 87 After a week of  Note presence and location able to demonstrate
O2 SAT- 99% ART Nursing Intervention of traction device Assess for the traction device such behavior and lifestyle
BP- the patient will be skin color and temperature as tr band may impede changes to improve
142/70 able to demonstrate in all extremities circulation to the limb circulation
behavior and  Assess for skin color and
lifestyle changes to temperature in all To maximize systemic
improve circulation extremities circulation
 Discuss relevant risk factors
Information necessary
such as smoking,
for client to make
hypertension, diabetes, and
informed choices about
clotting disorders
remediating risk and
Dependent committing to lifestyle
changes
 Treatment of underlying
Dependent
condition of Hypertension
and Diabetes Mellitus
to check for changes
 Administer medications
that might indicate
such as antiplatelet agents
circulation problems
and anti-pain medications

Collaborative
Refer to the physician to give focus
on his condition to improve tissue
perfusion