Nursing care plan

Assessment Nursing Goal & Nursing Rationale Evaluation

diagnosis Evaluation Intervention
Criteria
Subjective Nursing Goal Independent: STG: After
Data : I diagnosis STG : After 8 1. Monitor VS at 1. To monitor 8 hrs of
usually have Ineffective hrs of nursing least q 1-2 hrs and baseline data. nursing
symptoms Tissue interventions, prn. 2. Caffeine is intervention
like fainting Perfusion : blood pressure 2. Encourage a cardiac s, blood
and Cardiopulmonar will be within patient to decrease stimulant and pressure
tiredness, as y, set intake of caffeine, may maintained
verbalized by Gastrointestinal parameters for cola and adversely within set
the patient. and Peripheral the client. chocolates. affect cardiac parameters
r/t hypertension LTG : After 6 function. for the
Objective and decreased days of 3. These flugs client. Goal
Data: Cardiac output nursing 3. Administer have rapid was met.
- Tachycardia as manifested interventions, vasoactive drugs action and LTG : After
- Shortness by blurred the client will and titrate as may decrease 6 days of
of breath vision and have an ordered to maintain the blood nursing
- Cool, increased blood adequate pressures at set pressure too intervention
clammy skin pressure tissue parameters for rapidly, s, the client
- Optic disc perfusion to patient. resulting in had an
papilledema his body complications. adequate
- Increased systems. 4. May tissue
Assessment Nursing Goal & Nursing Rationale Evaluation
diagnosis Evaluation Intervention
Criteria
blood 4. Observe for indicate perfusion to
pressure Evaluation complaints of cyanide his body
Criteria blurred vision, toxicity from systems.
1. Normal tinnitus or increasing Goal was
blood pressure confusion. intracranial met
(< 140/90 pressure.
mm.Hg) 5. Monitor I&O 5. I&O will
2. Dont have status every 8 hrs. give an
signs and indication of
symptoms of fluid balance
blood to the or imbalance,
body's thus allowing
ineffective for changes in
such as treatment
- Headache 6. Monitor for regimen when
- Blur vision sudden onset of required.
- Tachycardia chest pain. 6. May
- Shortness of indicate
breath 7. Monitor ECG for dissecting
- Cool, changes in rate , aortic
clammy skin rhythm, aneurysm.
dysrhythmias and 7. Decreased
Assessment Nursing Goal & Nursing Rationale Evaluation
diagnosis Evaluation Intervention
Criteria
conduction defects. perfusion may
result in
8. Observe dysrhythmias
extremities for caused by
swelling, erythema, decrease in
tenderness and oxygen.
pain. Observe for 8. Promotes
decreased venous stat is
peripheral pulses, which an
pallor, coldness increase the
and cyanosis. risk of
thromboembo
lus formation.
If treatment is
too rapid and
aggressive in
decreasing
9. Instruct client in the blood
signs/symptoms to pressure,
report to physician tissue
such as headache perfusion will
upon rising, be impaired
Assessment Nursing Goal & Nursing Rationale Evaluation
diagnosis Evaluation Intervention
Criteria
increased blood and ischemia
pressure, chest can result.
pain, shortness of 9. Promotes
breath, increased knowledge
heart rate, visual and
changes, edema, compliance
muscle cramps and with
nausea and treatment.
vomiting. Promotes
prompt
detection and
facilitates
prompt
intervention