ASSESSMEN NURSING OBJECTIVE INTERVENTION RATIONALE EVALUATION

T DIAGNOSIS

Objective cues: Deficient fluid General: 1. Assessed patient’s vital 1. To evaluate After 6 hours of nursing
- edema volume related to After 6 hours of signs (BP, temperature, PR, degree of fluid interventions, patient was
formation on protein loss as nursing and RR) and noted strength of deficit. able to attain normal
the extremities evidenced by interventions, peripheral pulses. conditioning, participated
edema, visual patient will: -Independent nursing 2. To more in the actions which
- visual changes changes, and dry intervention accurately improved body’s normal
mouth with a.) be able to know 2. Observed urinary output, determine fluid volume, and was able
- dry mouth and cracked lips. the causative color, and measured amount replacement to know the causative
cracked lips factors that affects and specific gravity. needs. factors that affect high BP.
the sudden Measured or estimated other 3. To evaluate
increase of BP fluid losses. degree of fluid
during pregnancy. -Inependent nursing deficit.
intervention 4. To assess
b.) demonstrate a 3. Reviewed laboratory data. causative/precipit
positive attitude -Collaborative nursing ating factors.
toward the nurse’s intervention 5. To correct or
teachings. 4. Evaluated nutritional replace fluid
status, noted current intake, losses to reverse
weight changes, and problems pathophysiologica
with oral intake. l mechanisms.
Specific: -Independent nursing 6. To maintain
Within 6 hours of intervention skin integrity and
nursing 5. Provided nutritious diet via prevent excessive
interventions, appropriate route; gave dryness.
patient will: adequate free water with 7. To prevent
enteral feedings. injury from
a.) maintain fluid -Dependent nursing dryness.
volume at a intervention 8. Early
functional level. 6. Bathed less frequently identification of
using mild cleanser/soap, and risk factor can
b.) attain stable provided optimal skin care decrease
vital signs. with suitable emollients. occurrence and
-Independent nursing severity of
c.) have moist intervention complications
mucous 7. Provided frequent oral associated with
membranes. care. hypovolemia.
-Independent nursing
intervention
8. Discussed factors related to 9. Alcohol or
occurrence of deficit, as caffeinated
individually appropriate. beverage tends to
-Independent nursing exert a diuretic
intervention effect.
9. Instructed to limit intake of
alcoholic/caffeinated
beverages.
-Independent nursing 10. To promote
intervention comfort and
10. Changed position safety.
frequently.
Subjective cue: Decreased General: 1. Monitored blood pressure 1. Comparison of pressures After 6 hours of nursing
“Nabantayan cardiac output After 6 hours of of the patient. Measured in provides a more complete picture interventions, patient was
nako nga murag related to nursing both arms or thighs three of vascular involvement or scope able reduce blood pressure
nikalit lang ug decreased interventions, the times, 3-5 minutes apart of the problem. or cardiac workload and was
dako akong venous return. patient will while patient was at rest, 2. Presence of pallor, cool, skin able to identify the signs of
timbang” as reduce blood then seated, then stood for moist, and delayed capillary refill cardiac decompensation.
verbalized by the pressure or initial evaluation. time may be due to peripheral
patient. cardiac -Independent nursing vasoconstriction.
workload. intervention 3. May indicate heart failure, renal
Objective cues: or vascular impairment.
- variations in Specific: 2. Observed skin color,
blood pressure After 6 hours of moisture, temperature, and 4. These restrictions can help
nursing capillary refill time. manage fluid retention and with
- edema on the interventions, the -Independent nursing associated hypertensive response,
extremities patient will be intervention which decrease cardiac workload.
able to identify 5. To minimize/correct causative
- vital signs the signs of factors, maximize cardiac output.
taken as follows: cardiac 3. Noted dependent or 6. Reduces physical stress and
BP= 150/120 decompensation. general edema. tension that affect blood pressure
mmHg -Independent nursing and course of hypertension.
intervention 7. Can reduce stressful stimuli,
PR= 96 bpm produce calming effect thereby
4. Implemented dietary reduce blood pressure.
RR= 24 cpm sodium, fat, and cholesterol 8. Help reduce sympathetic
restrictions as indicated. stimulation, promotes relaxation.
T= 36.6 C -Collaborative nursing 9. To promote venous return.
intervention 10. Provides encouragement and
promotes wellness.

5. Avoided the use of

restraints. May increase
agitation and increase the
cardiac workload.
-Independent nursing
intervention
6. Maintained activity
restrictions.
-Independent nursing
intervention

7. Instructed in relaxation
techniques, and guided
imagery.
-Independent nursing
intervention

8. Provided calm, restful

surroundings, minimized
environmental noise.
-Independent nursing
intervention

9. Provided for adequate

rest, positioned patient for
maximum comfort.
-Independent nursing
intervention

10. Gave information about

positive signs of
improvement, such as
decreased edema, improved
vital signs/circulation.
-Independent nursing
intervention
Vital signs taken Ineffective General: 1. Monitored blood 1. For baseline information. After 6 hours of nursing
as follows: tissue perfusion After 6 hours pressure every 2 hours. 2. To note degree of interventions, patient was able to
related to of nursing -Independent nursing impairment or organ know the factors that affect her
BP= 150/120 vasoconstriction interventions, intervention involvement. condition, verbalized
mmHg of blood vessels. the patient 2. Determined presence 3. Sodium tends to be excreted understanding of condition, and
will be able to of visual, sensory/motor at a faster rate. demonstrated behaviors that
PR= 96 bpm know the changes, headache, 4. To control the blood improved circulation.
factors dizziness, altered mental pressure and to avoid other
RR= 24 cpm affecting her status, personality complications.
condition. changes. 5. To note degree of
T= 36.6 C -Independent nursing impairment.
Specific: intervention 6. To promote wellness.
After 6 hours 3. Instructed to eat low 7. Promotes wellness.
of nursing and salt low fat diet. 8. To know whether patient’s
interventions, - Independent nursing condition has changed or not.
the patient intervention 9. To assess causative or
will be able to 4. Administered anti- contributing factors.
verbalize hypertensive drug
understanding prescribed by the 10. Enhances venous return.
of condition physician.
and -Dependent nursing
demonstrate intervention
behaviors to 5. Noted reports of
improve nausea/vomiting.
circulation. -Independent nursing
intervention
6. Encouraged
discussion of feelings
regarding
prognosis/long-term
effects of the condition.
-Independent nursing
intervention
7. Referred to specific
support groups,
counseling, as
appropriate.
-Collaborative nursing
intervention

8. Evaluated vital
signs, noted changes in
BP, heart rate, and
respirations.
-Independent nursing
intervention

9. Evaluated for signs

of infection, especially
when immune system is
compromised.
-Independent nursing