ASSESSMEN NURSING PLANNING NURSING RATIONALE EVALUATION

T DIAGNOSIS INTERVENTION
SUBJECTIVE INEFFECTIVE WITHIN 1-2 GOAL MET, AFTER
“ I FEEL TISSUE PERFUSION HOURS PATIENT >ESTABLISH RAPPORT >TO GAIN 2 HOURS OF
WEAK AND RELATED TO WILL BE ABLE TO COOPERATION NURSING
DIZZY” DECREASE MAINTAIN TISSUE OF THE PATIENT INTERVENTION
CARDIAC OUTPUT PERFUSION TO PATIENT WAS
OBJECTIVE VITAL ORGANS, ABLE TO
>VITAL AS EVIDENCED >EVALUATION MAINTAIN TISSUE
SIGNS BY WARM AND >ASSESS FOR VITAL PROVIDES A PERFUSION TO
HR190BPM  DRY SKIN, SIGNS BASELINE FOR VITAL ORGANS,
BP148/96- PRESENT AND FUTURE AS EVIDENCED BY
MMHG STRONG COMPARISON WARM AND DRY
RR-25CPM PHERIPHERAL SKIN, PRESENT
TEMP. 37.6. PULSES, VITAL >HYPOXIA AND STRONG
C SIGNS WITHIN > MONITOR INFLUNCE PHERIPHERAL
SPO2- 96% NORMAL RANGE, NEUROLOGIC STATUS CEREBRAL PULSES, VITAL
AT ROOM BALANCED PERFUSION, IT SIGNS FR- 70BPM ,
AIR 1&O,ALERT, IS DIRECTLY BP 120/80MMHG ,
>CONSCIOU ORIENTED RELATED TO BALANCED 1&O, ,
S CARDIAC ALERT , AND
>COHERENT OUTPUT ORIENTED
>WITH >TO MONITOR
WEAK >HOOKED TO CARDIAC ANY ECG
PERIPHRAL MONITOR TO MONITOR RHYTHM
PULSE ECG FOR RATE , ABNORMALITIE
BUT EQUAL RHYTHM AND S
>COLD CONDUCTION.
CLAMMY >REDUCED
SKI N >MONITOR I&O INTAKE MAY
>HAS EASY CONSEQUENTLY
FATIGABILI LOWER
TY CIRCULATING
VOLUME,
WHICH
NEGATIVELY
 AFFECTS
PERFUSION AND
ORGAN
FUNCTION,

>PUT ON BED REST >ORTHOSTATIC

HYPOTENSION
RESULTS TO
TEMPORARY
DECREASE
CEREBRAL
PERFUSION
>PROVIDE QUIET >CONSERVE
RESTFUL ENERGY
ATMOSPHERE. LOWERS TISSUE
O2 DEMAND

>EDUCATE TO AVOID >THESE WILL

MEASURE THAT MAY FURTHER
TRIGGER INCRESE ICP REDUCED
SUCH AS STRAINING CEREBRAL
AT STOOL, HEAD FLAT, BLOOD FLOW
OR BEARING DOWN

>ENCOURAGE >TO LESSEN

VERBALIZATION OF ANXIETY
FEELINGS AND
CONCERNS.

COLLABORATIVES:
>ADMINISTER >IT ENHANCES
SUPPLEMENTAL MYOCARDIAL
OXYGEN AS PERFUSION
INDICATED.
>ADMINISTER IVF AS >SUFFICIENT
PRESCRIBED. FLUID INTAKE
MAINTAINS
ADEQUATE
FILLING
PRESSURE AND
OPTIMIZE
CARDIAC
OUTPUT
NEEDED FOR
PERFUSION

>ADMINISTER >THESE
MEDICATION AS MEDICATION
PRESCRIBED. FACILITATE
PERFUSION FOR
MOSTR CAUSES
OF IMPAIRMENT