DATE/TIME CUES NEED NURSING OBJECTIVE OF CARE NURSING INTERVENTIONS EVALUATION
DIAGNOSIS
A Subjective cues: P Decreased Cardiac After 8 hours of nursing Independent:
P “Murag huot H Output related to intervention, the patient A. Monitor vital signs, especially
R akong dughan Y elevated blood will be able to: heart rate and blood pressure.
I gamay day” as S pressure as evidenced R: To detect changes in blood
L verbalized. I by BP of 180/130 A. Display pressure or overall health status
“Lisod lng O hemodynamic
15 gamay e L Rationale: stability such as B. Monitor breath sounds,
ginhawa day” as O When the resistance blood pressure. respiratory rate and pattern,
2 verbalized G against which the B. Demonstrate and oxygen saturation
0 I heart must pump blood decreased R:
2 Objective cues: C increases, such as in episodes of
4 BP-160/120 conditions like dyspnea, angina, C. Monitor heart rhythm
RR-27 N hypertension, the heart and arrhythmia Rationale:
8AM Irregular pulse E has to work harder to C. Participate
noted. E overcome this activities that D. Assess and monitor for client
D resistance, leading to reduce the reports of chest pain
S decreased cardiac workload of the R:
output heart such as
Abraham Maslow’s stress E: Evaluate client reports and
hierarchy of need Reference: management, evidence of extreme fatigue,
therapeutic intolerance for activity, and
medication progressive shortness of breath
regimen, and R:
balanced
activity/rest plan E. Monitor patient’s activity level
R: Patients may become fatigued
more quickly when cardiac output
is low
F. Elevated the head of the bed
R: It will allow the patient for
better positioning for breathing
and be able to maintain an
appropriate oxygenation level.
G. Encouraged adequate bed
rest
R:
H. Encouraged relaxation
techniques
R: To reduce anxiety, muscle
tension, and conserve energy
I. Encouraged to avoid salty and
fatty foods
R:
Dependent:
DATE CUES NEED NURSING OBJECTIVE OF CARE NURSING INTERVENTIONS EVALUATION
DIAGNOSIS
