ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Decreased Cardiac STG: 1.monitor BP every 1. changes in BP STG:

“madalas ako Output r/t malignant After 6 hrs of 1-2 hours, or every may indicates After 6 hrs of
mahilo”, as hypertension as nursing 5 minutes during changes in patient nursing
verbalized by the manifested by interventions, the actve titration of status requiring interventions, the
patient. decreased stroke client will have no vasoactive drugs. prompt attention. client had no
volume. elevation in blood 2. monitor ECG for 2. decrease in elevation in blood
pressure above dysrrhythmias, cardiac output may pressure above
Objective: normal limits and conduction defects result in changes in normal limits and
>lethargic will maintain blood and for heart rate. cardiac perfusion will maintain blood
>decreased cardiac pressure within causing pressure within
output acceptable limits. dysrhythmias. acceptable limits.
>decreased stroke 3. suggest frequent 3. it may decreases Goal was met.
volume LTG: position changes. peripheral venous
>increased After 5 days of pooling that may be LTG:
peripheral vascular nursing potentiated by After 5 days of
resistance interventions, the vasodilators and nursing
>VS taken as client will maintain prolonged sitting or interventions, the
follows: adequate cardiac standing. client maintained an
T: 37.2 output and cardiac 4.encourage patient 4. caffeine is a adequate cardiac
PR: 83 index. to decrease intake of cardiac stimulant output and cardiac
RR: 18 caffeine, cola and and may adversely index.
BP: 180/100 chocolates. affect cardiac Goal was met.
function.
5. observe skin 5. peripheral
color, temperature, vasoconstriction
capillary refill time may result in pale,
and diaphoresis. cool, clammy skin,
with prolonged
capillary refill time
 due to cardiac
dysfunction and
decreased cardiac
output.
6.auscultate heart 6. hypertensive
tones. patients often have
S4 gallops caused
by atrial
hypertrophy.
7. administer 7. to promote
medicines as wellness.
prescribed by the
physician.
8. instruct client & 8. restrictions can
family on fluid and assist with decrease
diet requirements in fluid retention
and restrictions of and hypertension,
sodium. thereby improving
cardiac output.
9. instruct client and 9. promotes
family on knowledge and
medications, side compliance with
effects, drug regimen.
contraindications
and signs to report.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective Tissue STG: 1. monitor VS at 1.to monitor STG:

“ Laging sumasakit Perfusion: After 8 hrs of least q 1-2 hrs and baseline data. After 8 hrs of
ang aking ulo at Cardiopulmonary, nursing prn.. nursing
parang nanlalabo Gastrointestinal and interventions, blood 2. encourage patient 2. caffeine is a interventions, blood
ang aking Peripheral r/t pressure will be to decrease intake of cardiac stimulant pressure maintained
paningin”, as hypertension and within set caffeine, cola and and may adversely within set
verbalized by the decreased cardiac parameters for the chocolates. affect cardiac parameters for the
patient. output as client. function. client.
manifested by .3. administer 3. these frugs have Goal was met.
Objective: blurred vision and LTG: vasoactive drugs rapid action and
 Tachycardia increased blood After 6 days of and titrate as may decrease the LTG:
 Shortness of pressure.. nursing ordered to maintain blood pressure too After 6 days of
breath interventions, the pressures at set rapidly, resulting in nursing
 >rales client will have an parameters for complications. interventions, the
 Restlessness adequate tissue patient. client had an
 Cool, perfusion to his 4. observe for 4. may indicate adequate tissue
clammy skin body systems. complaints of cyanide toxicity perfusion to his
blurred vision, from increasing body systems.
 Optic disc
tinnitus or intracranial Goal was met.
papilledema
confusion. pressure.
 Increased 5. monitor I&O 5. I&O will give an
blood status. indication of fluic
pressure. balance or
imbalance, thus
allowing for
changes in
treatment regimen
when required.
6. monitor for 6. may indicate
sudden onset of dissecting aortic
chest pain. aneurysm.

7. monitor ECG for 7. decreased

changes in rate, perfusion may result
rhythm, in dysrhythmias
dysrhythmias and caused by decrease
conduction defects. in oxygen.
8. observe 8.Bedrest promotes
extremities for venous statis which
swelling, erythema, can increase the risk
tenderness and pain. of thromboembolus
Observe for formation. If
decreased peripheral treatment is too
pulses, pallor, rapid and aggressive
coldness and in decreasing the
cyanosis. blood pressire,
tissue perfusion will
be impaired and
ischemia can result.
9. instruct client in 9. promotes
signs/symptoms to knowledge and
report to physician compliance with
such as headache treatment. Promotes
upon rising, prompt detection
increased blood and facilitates
pressure, chest pain, prompt intervention.
shortness of breath,
increased heart rate,
visual changes,
edema, muscle
cramps and nausea
and vomiting.