ASSESMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS

Subjective: Decreased cardiac -After the nursing Independent: -Comparison of After the nursing
“Nagulat ako kasi output r/t decreased interventions, the -Monitor the blood pressures provide intervention the client
biglang tumaas ang venous return. patient will be able to pressure of the more picture of the was able to:
timbang ko.” As participate in the patient after every 15 scope of the
verbalized by the activities that reduce minutes. problem.  Display
client blood pressure or hemodynamic
cardiac workload. -Observe skin color, -Presence of pallor, stability
Objective: moisture, cool, moist skin and
Variations in blood temperature and delayed capillary  Verbalize
pressure. capillary refill time. refill time may be due knowledge of
Edema. to peripheral disease process,
-Note for edema. vasoconstriction. the individual
V/S risk factors and
Temp: 37.1C -Lessen the -May indicate heart the treatment
PR: 82 environmental failure, renal or plan
RR: 20 activity or noise. vascular impairment.
BP: 160/90  Identify signs of
-Instruct in relaxation -Promotes relaxation cardiac
techniques. and reduce decompensation
sympathetic and seek help
Collaborative: stimulation. appropriately.
-Implement dietary
restriction as -Reduce physical
indicated. stress and tension
that affect course of
hypertension.