ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS

SUBJECTIVE: Decreased SHORT TERM: 1. Monitor pulse rate 1. To provide SHORT TERM:
Cardiac Output and blood pressure; vital baseline;
“Taas gyud na iyang Related to Within 15 minutes Within 15 minutes
blood pressure, naa Increased of interventions 2. Check for 2. Decreased of interventions
shay maintenance Vascular the client will be alterations in the cerebral the client was able
para ana” as Vasoconstriction level consciousness; perfusion and to demonstrate
verbalized by wife able demonstrates hypoxia are adequate cardiac
adequate cardiac 3. Record intake and reflected in output as
output as output; irritability, evidenced by
evidenced by perfusion. blood pressure
OBJECTIVE: blood pressure 4. Ensure patient and pulse rate
remains on bed rest 3. Reduced with client
- Increased and pulse rate or maintains activity cardiac output baseline
BP=160/100 within client level that does not results in parameter.
with decrease baseline compromise cardiac reduced
PR=48 bpm parameters. output; perfusion of the LONG TERM:
- Weak and kidneys, with a
thready on resulting Within 4 hours of
both left and LONG TERM: decrease in interventions the
right radial urine output. client was free
pulse. Within 4 hours of
- Skin cool to 4. Restriction of from
interventions the
touch and activity often complications
client will be free
pallor noted facilitates associated with
with CRT= from temporary decreased cardiac
<2secs complications compensation. output i.e
- Change in associated with
level of decreased level of
decreased cardiac
consciousnes consciousness,
s compared to output i.e fatigue,
baseline of decreased level of hypotension,
being alert, consciousness, thready pulse and
awake and
verbally fatigue, chest pain.
responsive hypotension,
and able to thready pulse and
make needs chest pain.
known.