ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

EXPLANATION
Subjective: INNEFFECTIVE Accumulation of Discharge *determine factors *baseline date to Discharge
TISSUE fatty deposit, Outcome: related to individual know the Outcome:
“SUmisikip ang PERFUSION platelet, situation (e.g history/risk causative factor
dibdib ko” as related to impaired neutrophils, After 1 wk of for formation of After 1 wk of
stated by the o2 traportation monocyte, nursing thrombus) nursing
client AEB dyspnea and macrophage intervention the intervention the
irregular heart rate throughout the client will be able *determine duration of *baseline for the client had been
and rhythm. tunica intemia and to demonstrate problem/frequency of degree of able to
eventually into the increase perfusion recurrence problem demonstrate
tunica media as individually precipitating/aggravating increase perfusion
Objective: appropriate (e.g actors as individually
↓ skin warm/dry, appropriate (e.g
*dyspnea peripheral pulses *note degree of skin warm/dry,
*irregular heart -Increase serum present/strong, vs dyspnea, cyanosis, *to know the peripheral pulses
rate and rhythm cholesterol w/n normal range, hemoptysis severity of the present/strong, vs
*capillary longer -Increase bp alert/oriented, problem w/n normal range,
than 3sec -Increase blood balance i&o, *encourage quite, restful alert/oriented,
*nasal flaring iron levels absence of atmosphere balance i&o,
*chest retraction -Increase edema, free of *Conserve absence of
*dysrythmias homocysteine pain and energy/lower edema, free of
levels discomfort. *encourage use of tissue o2 demand pain and
relaxation techniques, discomfort.
↓ exercise. Establish *techniques to
Short term regular exercise decrease
Dysfunction of the Outcome: program pain/tension Short term
endothytial cell Outcome:
lining After 8hrs of *recommend avoidance
nursing of vasoconstricting drug After 8hrs of
↓ intervention the *it may block or nursing
 client will be able *discuss preventing slowers blood intervention the
Permeability of to verbalize exposure to cold, return client had been
fatty acids and understanding of dressing warmly and able to verbalize
triglycerides condition, therapy use of natural fibers to *to not aggravate understanding of
regimen, side retain heat more the situation condition, therapy
↓ effects of efficiently regimen, side
medication and effects of
Production of o2 when to contact *early ambulation medication and
free radicals w/c health care when to contact
damages the provider. *enhances health care
vessel *discourage venous return provider.
sitting/standing for long
↓ periods, wearing *enhances
constrictive clothing venous return
Inflammatory
response Collaborative:

↓ *administer o2 as
prescribe.
Cold, senisitivity, *increase o2 in
lower extramities the body
and chest pain,
shortness of
breath, paleness,
change in the
color of the skin

-gayton, 1581