Wesleyan University of the Philippines

Cushman Campus
Mabini Extension Cabanatuan City Philippines 3100

Joanne Tomas
BSN 3-2

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective: Insufficient cardiac Short Term: Independent: Short Term:

"Napapansin ko output related to  After 3 hours  Institute  To establish  After 3 hours
napapadalas yung decreased venous of nursing trust/rapport therapeutic of nursing
mabilis na pagtibok ng return secondary to interventions, to the client. relationship, interventions,
puso ko tapos lagi severe pre-eclampsia the patient's (Nurse-Patient the client's the patient's
kong hinahabol ang as evidenced by blood pressure Interaction) trust and blood pressure
hininga ko. Madalas altered blood pressure will return to  Observe and participate in returns to its
din ang aking and edema its normal level monitor for the normal level
pagkapagod. Hirap din and stability of the patient's intervention. and stability of
ako makatulog sa gabi the patient's vital signs.  To obtain the the patient's
at makapagpahinga ng hemodynamic  Assess overall baseline as hemodynamic
maayos."As verbalized AEB will show. physical well- record from AEB show.
by the patient being and the client.
Long term: status of the  To distinguish Long term:
Objective:  After 3 days of client. any signs of  After 3 days of
The client can has: nursing  Check for the diseases. nursing
 Changes in interventions, peripheral  Provides interventions,
blood pressure the client will pulses and opportunities the client
 Restlessness display impending to track displays
exercises that shock. changes and exercises that
will help to to prevent will help to
regulate the  Provide a dark hypovolemic regulate the
 Wesleyan University of the Philippines
Cushman Campus
Mabini Extension Cabanatuan City Philippines 3100

blood flow and quiet shock. blood flow

effectively room with the  To promote effectively
toward the temperature's adequate toward the
heart and comfortable to sleep, rest and heart and
decreases the the client. privacy. decreases the
activities that  Promote deep  To reduce the activities that
contribute to breathing risk for contribute to
the workload exercises valsalva effect the workload
of the heart during and to of the heart
such as activities regulate the such as
balanced  Provide body normal balanced
activity, rest emotional system due to activity, rest
plan, regimen support compensatory plan, regimen
in taking measures to mechanisms. in taking
medications, the client.  To provide medications,
management comfort and management
of stress and Interdependent: decreases of stress and
anxiety.  Keep the trunk anxiety. anxiety.
of the client in  To promote
a horizontal the flow of
position and blood and
place the it on venous return.
the Head of
Bed raising the
legs at about
20-30 degrees.
 Elevate
edematous  To provide
 Wesleyan University of the Philippines
Cushman Campus
Mabini Extension Cabanatuan City Philippines 3100

extremeties comfort
and educate measures and
the client to prevent fluid
wear build-up
compression especially in
stockings. the
 Encourage extremities
changing  To reduce the
positions risk of
Collaborative: Orthostatic
 Provide hypotension
oxygen and and to
medications as promote good
needed. blood flow.
 To rise the
levels of
oxygen in the
tissue, blood
and on the
organs.