25

ASSESSMENT NURSING SCIENTIFIC BASIS GOALS/DESIRE INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS D OUTCOME
SUBJECTIVE: Ineffective Reduced Short Term: INDEPENDENT: Goals partially
“Maglisud ko’g Peripheral and After 2 days of 1. Assess for signs of -Specific clusters of signs and symptoms met as
arterial blow decreased tissue occur with differing etiologies.
ginhawa”, Cardiopulmonar duty, patient evidenced by:
- as verbalized by the y Tissue
flow due to will be able to perfusion. (Gulanick/Myers:NCP,2007,p198)
pt. perfusion severe vaginal improve tissue -Patient’s pulse
related to bleeding from perfusion as 2. Monitor quality of all -Assessment is needed for ongoing rate is reduced
OBJECTIVE: hypovolemia complete evidenced by: pulses. comparisons, loss of peripheral pulses must from 130 to 120
-Tachycardia: Pulse and immobility hydatidiform  Patient’ be reported or treated immediately. bpm
rate of 130 bpm secondary to s (Gulanick/Myers, NCP,2007,p199)
- Arrythmias noted hydatidiform mole causes -Pt verbalizes
capillary
mole decrease refill 3. Encourage quiet, -Conserves energy/ lowers tissue O2 understanding
-Tachypnea: nutrition and restful atmosphere. demands. on health
less (Doenges et al, Nurses Pocket Guide,
Respiratory rate of 32 oxygenation at than 3 teachings
11th,2008, p. 710)
cpm cellular level. seconds
. 4. Elevate HOB at night -to increase gravitational blood flow -Capillary refill
- Capillary refill of 5  Pulse (Doenges et al, Nurses Pocket Guide, of 4 seconds
seconds with less than (Robbins. 11th,2008, p. 711)
rate
3 as the normal Physiology and within -Respiratory
Pathology of 60-100 5. Avoid massaging leg To prevent embolus rate reduced
-Non pitting edema on (Doenges et al, Nurses Pocket Guide, from 32 cpm to
Disease.2005. bpm 11th,2008, p. 711)
the lower extremities 25
with the grade of 1+ p 1086)  Respirat
ory rate 4. Caution client to avoid - Conserves energy/ lowers tissue O2
barely detectable with -Demonstrates
within activities that increase demands.
4+ as the highest in a cardiac workload. (Doenges et al, Nurses Pocket Guide, relaxation
normal
four point scale of (straining at stool) 11th,2008, p. 710) techniques
range
grading edema independently
12-
20cpm.
-Weak, thready pulse 5. Monitor for signs and -Decreased cardiac output leads to an
 Ability symptoms of hypoxia: insufficient supply of oxygenated blood to
at the upper
to a. Increased and irregular meet the metabolic needs of tissues.
extremities Brachial
pulse 1+ weak, easily
demons pulse rate Decreased circulating volume/cardiac
obliterated 119 trate b. Increased respiratory output can result in hypoperfusion of the
right arm, 118 left arm relaxati rate kidneys and decreased circulation to
Radial pulse 1+ weak, on c. Decreased urine extremities and increased pulse and
thread, 130 right hand techniq output(less than 30ml respiratory rates. Changes in mentation
ues per hour may result from cerebral hypoperfusion.
d. Changes in mentation, Vasoconstriction and venous congestion in
-Vaginal bleeding for
 26

almost 2 months restlessness dependent areas produce changes in skin

reported e. Cool, moist, cyanotic, and pulses.
LABORATORY Long Term mottled skin (Carpenito, LJ. Lippincott Williams and
Hematocrit of 27% Goal: f. Decreased capillary Wilkins NCP 3rd.ed. 2006,p 65.)
refill time.
below the normal After 5 days of
which is 34-42% interaction with 8. Monitor laboratory -To evaluate patient’s status.
for females an patient and SO results. (Lippincott, Manual of Nursing
indication that with proper Blood tests Practice,8th ed.p.1262.)
patient had nursing -For blood replacement.
experienced loss intervention (Lippincott, Manual Nursing
and health Practice,8th ed.,Vol.2, p.1262)
teaching, pt DEPENDENT:
will verbalize 1. Obtain blood samples -For blotransfusion
and have 2-4 units of Gulanick,Myers:NCP,2007,p.201)
understandings
whole blood available as
on health indicated.
teachings,
demonstrate 2. Administer oxygen as -Increasing arterial oxygen saturation
relaxation ordered. delivers more oxygen the myocardium.
techniques. (Gulanick,Myers:NCP,2007,p.200)

DESIRED 3. Establish and maintain -To accommodate transfusion and large

IV line; start with a large quantities of fund.
OUTCOME:
needle. (Lippincott, Manual Nursing
-improve tissue Practice,8th ed.,Vol.2, p.1262)
perfusion
-verbalize COLLABORATIVE:
understanding 1. Do passive ROM Exercise prevents venous stasis and further
of health exercises to unaffected circulatory compromise.
teachings extremity every 2-4 (Gulanick/Myers:NCP,2007,p199)
-Pt does hours
relaxation .
-Teaching reinforces the need to comply
techniques
2. Assist with procedures with perceived treatments(diet, activity and
independently as indicated such as medications).
blood transfusion (Carpenito, LJ. Lippincott Williams and
Wilkins NCP 3rd.ed. 2006,p 65.)
27
HEALTH TEACHING: -To improve respiratory function/ oxygen
1. Teach the client and carrying capacitiy
family about condition (DOENGES, et al. Nurses Pocket Guide.
and its causes. 11th ed. 2008. Pg.340)

- outcome studies have shown multi-model

2. Explain the importance nonpharmacological therapy to significantly
of nonpharmacological improve functional capacity, body weight
interventions(relaxation and mood state.
strategies, self- (Carpenito, LJ. Lippincott Williams and
monitoring, exercise Wilkins NCP 3rd.ed. 2006,p 65.)
training.
- Regular exercise, such as walking, can
improve circulation and increase output
3. Explain the need to stroke volume & fatigue indicate
increase activity hypoxemia resulting from overexertion.
gradually and to rest if (Carpenito, LJ. Lippincott Williams and
dyspnea and fatigue Wilkins NCP 3rd.ed. 2006,p 65.)
occur.
- for pt. education & health maintenance.
(Lippincott, Manual Nursing
Practice,8th ed.,Vol.2, p.1262)
4. Advise the patient on
the need for continuous
follow-up care.