ASSESSMENT EXPLANATION OF OBJECTIVES NURSING RATIONALE EVALUA
THE PROBLEM INTERVENTIONS TION
Subjective: Normally, there is STO: within 2 Diagnostic Fully met: Magpapacheck- significant increase in hours of 1.) Assessed vital signs (BP, 1.) To determine the Patients up lang sana ako, blood pressure among nursing HR) effectiveness of BP: kaso nahilo at pregnant women interventions, intervention. 130/90, tumaas BP ko during their course of client will have 2.) Assessed peripheral 2.) To identify possible absence of pregnancy period. BP of less than extremities presence edema, dizziness It is a response of the or equal to varicosities or swelling. and Objective: body to the increase in 130/90mmHg, tingling Vital signs: blood volume. absence of Therapeutic sensation BP: However, it becomes dizziness and 1.) Administered 1.) To reduce blood fluid on both 150/100mmHg fatal if not monitored tingling magnesium sulfate via volume by means of hands. CR: 102 bpm regularly. sensation on solu-set increasing urine output. SpO2: 94% both hands 2.) To meet oxygen demand RR: 20 cpm Due to the increased 2.) Given low flow oxygen by the increased heart blood pressure, there (1-2 lpm) via nasal rate. cannula 3.) To allow full lung No signs of edema is a decreased cardiac 3.) Positioned to semi- expansion and allows on extremities due to increase in fowlers. more air to enter the Not distended heart rate resulting to lungs jugular vein inadequate blood No signs of pumped by the heart. 4.) Provided warm blanket 4.) To provide warmth. paleness Capillary refill and Decreased cardiac skin turgor less output is defined as Educative 1.) Taught deep breathing 1.) To reduce stimuli and than 1 second inadequate blood exercises produce calming effect With pulse grade pumped by the heart reducing BP of +2 to meet the metabolic 2.) Emphasized importance 2.) Lessens physical stress With tingling demands of the body. of adequate rest and and tension that affect sensation on both limit strenuous activities increase in blood hands pressure Not in respiratory References distress. Doenges, M., 3.) To increase venous 3.) Instructed to ambulate Moorhouse, M., & return. feet regularly Nursing Murr, A. (2009). Diagnosis Nurse's pocket guide. 4.) Instructed to report Decreased cardiac Philadelphia: Davis dizziness and difficulty 4.) To provide proper output related to Company. in breathing. medical and nursing increased heart management as needed. rate.
ASSESSMENT EXPLANATION OF OBJECTIVE NURSING RATIONALE EVALUAT
THE PROBLEM S INTERVENTIONS ION Subjective: It is normal for a STO: after 30 Diagnostic Fully met: Kinakabahan kasi person to get anxious mins of 1.) Assessed stressors 1.) To determine Patient was ako lagi kapag during clinical nursing contributing to anxiety appropriate able to nagpapacheck-up consultation or check- intervention interventions and relax as up. In the case of our patient will be evaluate degree of manifested patient, she gets in a relaxed Therapeutic anxiety by calm Objective: anxious every time she state as 1.) Use presence, touch 1.) Being supportive and face, able Observed to goes for a check-up, manifested by (with permission), approachable promotes to interact holding and reason was the result calm face and verbalization, and communication clearly, rubbing both may not desirable or non-shaky demeanor to remind understand hands. not as she expected as hands with patients that they are s the Noted to be texting claimed by the stable vital not alone and to situation , her son to come see patient. signs 2.) Diverted patient 2.) Talking or otherwise non-shaky her as soon as BP: =< attention. expressing feelings hands, and possible 130/90mmHg sometimes reduces vital signs Shaky hands And CR: < 100 anxiety. of BP: Vital signs: References: bpm Educative 130/90mm BP: 150/100mmHg 1.) Encourage expression or 1.) Talking about anxiety- Hg, CR: CR: 102 bpm Doenges, M., clarification of needs, producing situations and <100 bpm SpO2: 94% Moorhouse, M., & concerns, unknowns, anxious feeling can help the RR: 20 cpm Murr, A. (2009). and questions about patient perceive the situation Nurse's pocket guide. hospitalization. realistically and recognize Philadelphia: Davis factors leading Company. 2.) Taught deep breathing 2.) Promotes relaxation Nursing exercises and provided Diagnosis calm environment Anxiety related to 3.) Familiarize patient with 3.) Awareness of the hospitalization the environment and environment promotes new experiences or comfort and may people as needed. decrease anxiety experienced by the patient. Anxiety may intensify to a panic level if patient feels threatened and unable to control environmental stimuli.