PHINMA UNIVERSITY OF ILOILO

COLLEGE OF ALLIED HEALTH SCIENCES

Nursing Department

NURSING CARE PLAN

NURSING
ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION
INTERVENTIONS
OBJECTIVE: Ineffective tissue perfusion SHORT TERM: INDEPENDENT:
Nahihilo ako. Masakit ang related to vasoconstriction of After 1hour client will be able - Monitor vital signs  After 1hour client
batok ko.” as verbalized blood vessels to manifest increased tissue paticularly  To identify physical will be able to
perfusion. blood responses associated manifest increased
pressure. with medical tissue perfusion.
conditions.
- Perform assistive passive
range of motion.  ROM promotes
improved blood
SUBJECTIVE: - Provide quiet and restful circulation.
- Edema environment.
noted on LONG TERM:  It conserves
lower After 2 hours will be able to energy/lowers tissue  After 2 hours will be
extremities (grade 2) understand to understand oxygen demand. able to understand to
vasoconstriction of blood understand
DEPENDENT
- cold, vessels.
- Administer antihypertensive  Antihypertensives vasoconstriction of
clammy skin help decrease and blood vessels.
drugs as ordered.
noted. control blood
- Administer Magnesium pressure.
- capillary refill within 6
sulfate as ordered.
seconds  Magnesium sulfate
prevents or controls
- BP: seizures in pre-
140/100 eclampsia brought
about by vasospasm
secondary to
vasoconstriction of
blood vessels.

PREPARED BY: ARIANNE NICOLE PINUELA