ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Sub jec t i ve : Decreased • Af te r 8 hours Monitor blood Comparison of pressures provides a more
Kapoy kau s i r as ca rd iac outpu t o f nurs ing pressure of the complete picture of vascular involvement or Af te r 8 hours o f
verba l i zed by the re l a ted to i n te rven t i ons , patient. Measure scope of the problem. nurs ing
pat i en t dec reased the pat ien t wi l l in both arms or i n te rven t i ons ,
Ob jec t i ve : venous re tu rn . par t i c i pa te i n thighs three the pat i en t was
• Var i a t i ons i n ac t i v i t i e s tha t times, 3-5 ab le to
b lood reduce b lood minutes apart par t i c ipa te i n
pressu re . pressu re or while patient is at ac t i v i t i e s tha t
• Edema ca rd iac work rest, then sitting, reduce b lood
• V/S taken as l oad . then standing for pressu re or
f o l l ows : initial evaluation. Presence of pallor, cool,moist skin and delayed
ca rd iac work
T: 37 .1 • Observe sk in capillary refill time may be due to peripheral l oad .
P : 78 color, moisture, Vasoconstriction
R: 20 temperature and
BP : 140 /90 capillary refill May indicate heart failure, renal or vascular
time. impairment.
• Note dependent Help reduce sympathetic stimulation, promotes
or general relaxation.
edema. Reduces physical stress and tension
• Prov ide ca lm,
restful
surroundings,
minimize
environmental Can reduce stressful stimuli, produce calming
activity or noise. effect, thereby reduce blood pressure.
• Main ta in ac t i v i t y
restrictions
Instruct in
relaxation
techniques, and These restrictions can help manage fluid
guided imagery. retention and with associated hypertensive
Collaborative: response, which decrease cardiac.
• Implement dietary
sodium, fat, and
cholesterol
restrictions as
indicated.