University of Perpetual Help System DALTA

Alabang Zapote Rd., Pamplona Las Pias City COLLEGE OF NURSING NURSING CARE PLAN Name of Patient: Jaime Gamlanga ASSESSMENT SUBJECTIVE:  Ok namanangpakiramd amko, as verbalized by the client. OBJECTIVE:  Alert, awake and responsive  (+)spontaneous, non-labored breathing  Capillary refill less than 4 seconds  (+) weakness  (+) weak, irregular pulse rate & rhythm  Temp 36.4C  PR 64bpm  RR 20cpm  BP 120/80 mmHg NURSING DIAGNOSIS Ineffective tissue perfusion related to impaired transport of O2 across capillary membrane as evidenced by weak, irregular pulse rhythm. Age: 79 years old PLANNING After 8 hours of nursing intervention, client will demonstrate increased perfusion with manifestation of regular pulse characteristics. Sex: M INTERVENTIONS  Established Rapport  Monitored and recorded vital signs  Monitored and recorded Intake and Output Diagnosis: Cardiac Arrythmia RATIONALE  To gain clients trust and cooperation  To establish baseline data  To determine fluid volume relative to oxygen transportation and circulation  Quiet atmosphere conducive to rest alleviates stress which aids the heart in proper function  Activities that requires too much work load leads to heart stress  These medications promote proper circulation and transportation of O2 Rm. / Bed No.: 504 EVALUATION Goal met. After 8 hours of nursing intervention, the client manifested regular and consistent pulse rhythm.

 Advised restful, quiet atmosphere

 Cautioned to avoid activities that increase the hearts work load  Administered Carvedilol, Erdosteine and KaliumDurule as ordered

Name of Student: Bartolome, Rhoel John V

Yr. Sec. &Grp No.: BSN 4D Group 4

Area & Shift: MCI 5th Floor Ward (2-10pm)