Assessment Nsg.

Scientific Planning Implementation Rationale Evaluation

Diagnosis basis
>S: >Ineffectiv Coronary >After 2 hours >Independent: After 2
-N/A e tissue arteries are of nursing 1. Investigate sudden 1. Cerebral perfusion is hours of
perfusio arteries that intervention, changes or continued directly related to cardiac nursing
>O: related to supply the the client will alterations in output and is also interventio
-Troponin 1 interruptio heart be able to: mentation (changes influenced by electrolyte n, goal
of 26 n of blood muscle with -maintains in LOC, mentation, and/or acid-base met, as
-cold and flow oxygen-rich maximum stupor). variations, hypoxia, and evidenced
clammy secondary blood. tissue systemic emboli. by:
extremities to Plaque is perfusion to 2. Inspect for pallor, 2. Systemic -Client
-fatigue myocardia made up of vital organs, as cyanosis, cool and vasoconstriction maintains
-hooked l infarction fat, evidenced by clammy skin. Note resulting from diminished maximum
with O2 at cholesterol, warm and dry strength of peripheral cardiac output may be tissue
2Lpm via calcium, skin, present pulses. evidenced by decreased perfusion
nasal and other and strong skin perfusion and to vital
cannula substance peripheral diminished pulses. organs, as
found in the pulses, vitals 3. Monitor vital signs 3. Cardiac pump failure evidenced
blood. within patient’s and neuru vital signs. and/or angina pain may by warm
Plaque normal range, precipitate respiratory and dry
>Vital signs: narrows the balanced I&O, distress and cause skin,
-BP: arteries and absence changes LOC. present
160/1000m reduces edema, alert 4. Decreased intake or and strong
4 Monitor intake,
mhg blood flow LOC, and note changes in urine persistent nausea may peripheral
-T: 36 C to your reduce chest result in reduced pulses,
output.
-P: 88bpm heart pain. circulating volume, which vitals
-R: 20cpm muscle negatively affects within
resulting in perfusion and organ patient’s
failure to function. normal
nourish 5. Assess GI 5. Reduced blood flow to range,
tissues at function: decreased mesentery can produce balanced
capillary or absent bowel GI dysfunction, e.g., loss I&O,
level. sounds, nausea and of peristalsis. Problems absence
>Reference vomiting, may be aggrevated by edema,
: constipation. decreased activity and alert LOC,
-http://www. diatary changes. and reduce
nurselabs.c 6. Encourage 6. Enhances venous chest pain.
om/anginap passive exercises. return, reduces venous
ectoris stasis, and decreases
risk of thrombophlebitis
7. Assess for 7.Indicators of deep vein
Homans’ sign (pain in thrombosis
calf on dorsiflexion),
erythema, edema.
8. Instruct patient in 8. Limits venous stasis,
application or improves venous return,
periodic removal of and reduces risk of
antiembolitic hose, thrombophlebitis in
when use patient who is limited in
activity.
>Dependent:
1. Attach patient to 1. Increases oxygen
Ow at 2Lpm, as available for myocardial
prescribed by the AP. uptake and reversal of
ischemia.
2. Administer 2. When beta-blockers
Bosoprolol fulmarate are used during the first
0.5mg OD as hours after the onset of
prescribed by the AP. MI, a reduction in infarct
size, mortality, and
nonfatal reinfarction may
occur.
>Collaboration:
1.Monitor laboratory 1. Indicators of organ
data: ABGs, BUN, perfusion and function.
coagulation studies
Assessment Nsg. Scientific Planning Implementation Rationale Evaluation
Diagnosis basis
>S: > Risk for When a >After 8 hours >Independent: >After 8
N/A Decrease blood of nursing 1. Assess vital signs. 1.Vital signs may be hours of
d Cardiac supply to a intervention, Auscultate apical elevated because of nursing
>O: Output part of heart the client will pulse; note heart increased SVR.The body interventio
-weakness related to is be able to: sounds; and palpate may no longer be able to n, goal
-fatigue changes interrupted, 1. Maintain peripheral pulses compensate and met, as
-bedrest in the resulting to hemodynamic hypotension may occur. evidenced
-sweating rate, decreased stability, e.g., 2. Check for calf 2. Reduced cardiac by: the
-Troponin I rhythm, blood BP, cardiac tenderness; output, venous client has
Elevated; cardiac supply to output within diminished pedal pooling/stasis, and able to:
26 conductio myocardium normal range, pulse; swelling, local enforced bed rest 1. Maintain
-hooked n, , resulting to adequate redness, or pallor of increases risk of hemodyna
with O2 decrease decreased urinary output. extremity. thrombophlebitis mic
Lpm via preload venous 2. Report 3. Monitor urine 3. Kidneys respond to stability,
nasal secondary return leads decreased output, noting reduced cardiac output e.g., BP,
cannula to to episodes of decreasing output by retaining water and cardiac
myocardia decreased dyspnea, and sodium. output
l infarction amount of angina. dark/concentrated within
blood 3. Demonstrate urine. normal
expelled by an increase in 4. Encourage rest, 4. Physical rest should range,
>Vital signs: ventricles activity Assist with physical be maintained during adequate
-BP: resulting to tolerance. care as indicated; acute or refractory HF to urinary
160/1000m decreased elevate legs. improve efficiency of output.
mhg cardiac cardiac contraction and 2. Report
-T: 36 C output. to decrease to decreased
-P: 88bpm >Reference myocardial oxygen episodes
:
-R: 20cpm demand. of
-http://www.
5. Have emergency 5. Sudden coronary dyspnea,
nurselabs.c
equipment and/or occlusion, lethal angina.
om/anginap
medications dysrhythmias, extension 3.
ectoris
available. of infarct, and Demonstra
 unrelenting pain are te an
situations that may increase in
precipitate cardiac activity
arrest, requiring
immediate life-saving
therapies and/or transfer
to CCU.
6. Review serial 6. Provides information
ECGs regarding progression or
resolution of infarction
>Dependent:
1. Hook to Oxygen at 1. Increases oxygen
2Lpm, as prescribed available for myocardial
by the AP. uptake and reversal of
ischemia.
2. Administer 2. When beta-blockers
Bosoprolol fulmarate are used during the first
0.5mg OD as pre hours after the onset of
scribed by the AP. MI, a reduction in infarct
size, mortality, and
nonfatal reinfarction may
occur.
>Collaboration:
1. Monitor laboratory 1. Indicators of organ
data, e.g., cardiac perfusion and function
enzymes, ABGs, 1. Enzymes monitor
electrolytes. resolution/extension of
infarction. Presence of
hypoxia indicates need
for supplemental oxygen.
Assessment Nsg. Scientific basis Planning Implementation Rationale Evaluation
Diagnosis
S: “Tag-as hypertensi Stimulation of After 8 >INDEPENDENT After 8
jud kog BP” on related vasomotor hours of 1. Assess underlying 1. To determine what hours of
As to center (loc in nursing condition. triggers the elevated BP nursing
verbalized elevated medulla) send intervention, 2. Monitor blood 2.Changes in BP may interventio
by the blood impulses to the client pressure for every30 indicates changes in n, goal
patient pressure CNS.Acethylcol will be able mins patients status requiring met, as
O: as ine released by to have a prompt medical attention evidenced
manifeste prostapregangli bloopd 3. Observe skin color, 3.Peripheral by patient
-headache d by onic neurons. pressur temperature, vasoconstriction may have a
-Dizziness headache Preganglionic within capillary refill, and result in pale, cool, bloopd
-Irritable in fiber releases. normal diaphoresis clammy skin,with pressur
times Norepinephrine range of prolonged capillary refill within
(constriction of 120/80 time normal
>Vital blood vessel mmHg 4. Do frequent 4.It may decreas range of
signs: there by positioning to the eperipheral venous 120/80
-BP: increasing patient. pooling that may mmHg
160/1000m blood pressure. potentiated by
mhg Adrenal vasodilators and prolong
-T: 36 C medulla sitting or standing
-P: 88bpm secrets 5. Encourage to 5. This are cardiac
-R: 20cpm epinephrine. decrease intakes of stimulant and may
Increased caffeine, cola ,and adversely affect cardiac
blood pressure chocolate function
causing it to 6. Emphasize the 6. Hypertension is
increase blood concept of controlling lifetime illness,
supply in the hypertension. controlling it is the best
brain causing way to stop it from
occipital reoccurring
headache. 7. Encouraged 7.Salty and fatty food are
patient to maintain one of the common
low salt low fat diet. cause of hypertension
>DEPENDENT
>Dependent: 1. Increases oxygen
1. Attach patient to available for myocardial
Ow at 2Lpm, as uptake and reversal of
prescribed by the AP. ischemia.
2. When beta-blockers
2. Administer are used during the first
Bosoprolol fulmarate hours after the onset of
0.5mg OD as MI, a reduction in infarct
prescribed by the AP. size, mortality, and
nonfatal reinfarction may
occur.
>Collaboration:
1.Monitor laboratory 1. Indicators of organ
data: ABGs, BUN, perfusion and function.
coagulation studies
ASSESSMENT DIAGNOSIS Scientific PLANNING INTERVENTION RATIONALE EVALUATION
Explanation
Subjective: Risk for Due to an After 4 hours INDEPENDENT After 4 hours
- none infection elective of nursing -Monitor vital -To establish a of nursing
related cesarean intervention, signs baseline data intervention,
Objective: inadequate section, patient will be patient was
- INCISION primary patient’s skin able to -Inspect -Moist from able to
SITE: Wound: defenses and tissue understand dressing and drainage can be understand
dry, no secondary to were causative perform wound a source of causative
discharges surgical mechanically factors, care infection factors,
noted Dressing incision interrupted. identify signs identified
and plaster Thus, the of infection - Monitor white - Rising WBC signs of
were clean and wound is at blood count (WB indicates body’s infection
fully covered risk of efforts to combat
the incision site developing pathogens;
-No foul odor infection.
noted on the - Monitor -these are signs
site. Elevated of infection
-WBC: 8.20 temperature,
(normal) Redness,
-VS swelling,
T: 37.3 increased pain,
P: 80 or purulent
R: 19 drainage at
BP: 120/80 incisions

- Wash hands -Friction and

and teach other running water
caregivers to effectively
wash hands remove
before contact microorganisms
with patient and from hands.
between Washing
procedures with between
patient. procedures
reduces the risk
of transmitting
pathogens from
one area of the
body to another

DEPENDENT
- Administer -Antibiotics have
antibiotics bactericidal
(Ampicillin) as effect that
ordered combats
pathogens
Assessment Nursing Scientific Objective Nursing Rationale Evaluation
diagnoses Explanation intervention
S: Acute pain r/t The client is After 2-4 hr of INDEPENDENT GOAL
“masakit talaga disruption of experiencing nursing >Monitor vital To have a PARTIALLY
ang tahi ko skin and tissue pain due to the intervention, the signs. baseline data. MET, After 2-4
incision done
maam” as the secondary to pt reported pain hr of nursing
to her after the
SO verbalized cesarean CS operation. will subside >Instruct the To prevent intervention,
-Pain Scale: section. Pain is a client to avoid bleeding of the the pt reported
5/10 typical sensory strenuous surgical incision pain reduced
experience that exercise and made from the AEB P/S of
O: may be activities. operation. 2/10
-facial described as
the unpleasant
grimaces >Instruct the To promote
awareness of a
noted noxious client to have a blood circulation
-Guarding stimulus or short walk and faster
behavior bodily harm. everyday as a healing of the
noted Individuals form of incision.
-Restlessness experience exercise.
noted pain by various
daily hurts and
-VS >Advise the To aid in
aches, and
T: 37.3 occasionally client to eat strengthening of
P: 80 through more plenty of having a good
R: 19 serious injuries nutritious foods Immune system
BP: 120/80 or illnesses. and vegetables against
and drink plenty infection.
of water.

DEPENDENT
>Give To relieve from
medication pain
(Tramadol)
ordered by the
physician.