Cues/Needs Nursing Rationale Goals and Intervention Rationale Evaluation

Diagnosis Objectives
Subjective: Impaired Cardiac After 8 hours of Dependent: The goal was
“kelan pa ba physical catheterization nursing met.
ako mobility r/t intervention, 1. Note This may
makakapaglaka prescribed Femoral sheath the patient will situations such restrict After 8 hour of
d kahit papunta movement removed be able to: as surgery movement nursing
lang sa CR?, restrictions intervention the
wala na kasi secondary to Direct manual 1. Verbalize 2. Note Feelings of patient was able
akong ginawa post operative pressure understanding emotional and frustration or to:
kundi humiga” coronary of situation and behavioral powerlessness
angiogram. Patient remain individual responses to may impede >verbalized
Objective: flat in bed treatment problems of attainment of understanding
>(+) discomfort regimen and immobility goals of situation and
>irritable Affected leg safety measures individual
>(+) weak straight 3. Provide for To enhance treatment
pulse 2. Demonstrate safety measures safety and regimen and
>post operative Immobility behaviors that as indicated by prevent other safety
coronary improves/ individual problems. measures.
angiogram enable situation,
VS: resumption of including >demonstrate
BP-120/80 activities environmental behaviors that
RR-20 Reference: management/ improves/
Temp.-36.0C 3. Maintain or fall preventions enable
PR- 60 Brunner and increase resumption of
Suddarh's strength and 4. Instruct client To develop activities.
madical-surgical function of to do active individual
nursing twelfth affected body ROM exercises exercise and >maintain or
edition part. of the upper increase
reduce risk of
extremities strength and
pressure ulcers. function of
Dependent: affected body
1. Administer To treat part.
analgesics and discomfort due
sedation as to bed rest and
doctor’s order. immobility.