ASSESSMENT EXPLANATION OF GOALS OF CARE NURSING RATIONALE EVALUATION

THE PROBLEM INTERVENTION

Subjective Decrease cardiac Long Term Long Term
Ang sakit sakit output there is an Objective Monitor and To obtain Objective
ng ulo ko, hindi inadequate blood After 72 hours of record Vital Signs baseline data Fully met if
ako makahinga pumped by the nursing
Tae ako n tae heart to meet the intervention the Note skin color, Skin pallor, or Partially met if
halos 5 days na metabolic patient will have and feel the mottling, cool or
minsan may demands of the DKO ALAM TO temperature of cold skin Not met if
kasama siyang body. There is the the skin temperature, or
dugo as suka ako need enough red Short Term an absent pulse Short Term
ng suka. Ta blood cells and Objective can signal arterial Objective
feeling ko lagi water in the After 8 hours of obstruction, Fully met if
akong uhaw. blood for the nursing which is an Partially met if
heart to push the intervention the emergency that Not met if
Minsan hindi fluids around patient the requires
parang within the blood patient will have immediate PAKILAGAY NLG
nacoconfuse siya vessels. In the Assess Jugular intervention INAANTOK NA ME
Good skin
kung asan siya. case of the Vein Distention
turgor.
Stated by patient, she was Jugular venous
Good
daughter experiencing pressure is low in
peripheral hypovolemic
severe diarrhea,
perfusion shock;
Objective vomiting and
(acral warm, it increases with
With cld and fluid loss, when
dry and red) effective treatment
clammy the body
Normal Vital and is significantly
extremities becomes increased
Signs
With capillart dehydrated, with fluid overload
refill of 1-3 there may be PAKICHECK NOT Review Hgb and and heart failure.
seconds enough red blood SURE TO Hct levels and
With rapid weak cells, but the note trends
pulse total volume of Decreased RBCs
Skin is noted to fluid is decreased can adversely
be pale with poor that leads to the affect oxygen
skin turgor. pressure within carrying
Lips appered the system capacity.This will
slightly blue decreases. determine if the
Observed Cardiac output is Record the input patient needs to
experiencing the amount of and output, urine undergoe Blodd
excessive blood that the specific gravity Transfusion
sweating heart can pump record Therapy
Complaints of out in one
extreme thirst, minute. If there
lightheadedness is less blood in Losing a lot of
and headaches the system to be fluids (through
Observed patient pumped, the vomiting,
is weak with heart speeds up diarrhea, diuresis,
narrowed focus to try to keep its diaphoresis) can
and complains of output steady. Position patient lead to severe
easy fatiguability Water makes up to Modified dehydration,
With Vital Signs about 90% of Trendeleburg concentrated
of: blood. If water is (The lower urine and body
BP: 80/30 lost or fluid extremities are weight
HR:45bpm intake is elevated to an decreased.
RR:20 inadequate, the angle of about 20
T: 35.3 body tries to degrees; the Increases blood
Urine output: 20 maintain cardiac knees are circulation and
ml/hr output by making straight, reduces pressure
the heart beat the trunk is on the pelvic
Decreased faster. But as the horizontal, and region
Cardiac Output fluid losses it the head is
related to increases the slightly elevated
__________(NOT body's )
SURE) compensation a
mechanisms
which can lead to Loosen Tight
decrease in BP Clothing
and HR with
decreased urine
output can result
to shock. Tight
clothing can
constrict
Begin an I.V.
breathing, further
infusion with reducing the
normal saline amount of
solution or oxygen carried to
lactated Ringers the brain

solution delivered
Initial goal is to
through a large correctcirculatory
bore. volumedeficit.Isot
onic saline
willrapidly
expandextracellul
ar fluid volume.
large bore (16 to
Start Blood 18 gauge)
Transfusion cannula for
therapy as per intravenous lines
physicians order was used to
replace volume
rapidly
 Hypovolaemia
occurs as a result
of blood loss due
Administer to trauma or
Oxygen as occurs peri-
ordered operatively, then
packed red blood
cells should be
replaced to
ensure that
Weigh the patient hypoxaemia does
daily, at the not occur
same time and
on the same
scale with patient To increase the
wearing the amount of
same amount of oxygen carried by
clothing available
hemoglobin in
the blood

To evaluate fluid
Maintain balance.
physic al rest
a n d emotional
rest by
providingquiet
and
relaxedenvironm
en
PAKIDAGDAGAN to reduce oxygen
NLG IF EVER demand and
toprevent
increasing
cardiac deman