OBJECTIVES CONTEXT STRATEGY TIME RESOURCES EVALUATION

ALLOTED
During the case
presentation the To be presented by Joehoney L. Barrera
student nurses will be
demonstrating the first NURSING DIAGNOSIS: Decreased Cardiac Output r/t
priority nursing care fluctuated BP as evidenced by decreased urine output
plan: Decreased Cardiac CUES
Output and expected to Subjective: Pt unable to speak c ETT. https://nurseslabs.com/category/nursing-
do the following: Objective: care-plans/cardiac/
-Fluctuated BP from 180/80 to 140/80 up to latest VS
Be able to explain the 130/80. LEAVE IT
NCPs and evaluate the -Fatigue BLANK
progress of the -Activity Intolerance
objectives if goal is met -Decreased Urinary output
or unmet. -Cardiomegaly and Atherosclerotic aorta result from
CXR
Be able to identify the OBJECTIVE :
objective cues After 3 days of nursing intervention, the pt will
manifested by our demonstrate increase cardiac output by maintaining
patient. stable blood pressure.
NURSING INTERVENTIONS & RATIONALE
Independent:
1. Monitor vital signs q1hr. To intervene appropriate
actions & monitor pt progress.
2. Record intake and output. If patient is accurately ill,
measure hourly urine output and note decreases in
output.
3. Limit fluids and sodium as ordered.
4. Closely monitor fluid intake including IV lines.
Maintain adequate fluid intake
5. Examine laboratory data such ABG, electrolytes,
CBC, Na level and serum creatinine
Dependent:
1. Notify primary healthcare when pt is not responsive
to treatment. To change treatment management.
EVALUATION:
After 3 days of nursing intervention patient wasn’t able
to maintain stable blood glucose level.
 OBJECTIVES CONTEXT STRATEGY TIME RESOURCES EVALUATION
ALLOTED
During the case
presentation the To be presented by Joehoney Barrera
student nurses will be NURSING DIAGNOSIS : Activity Intolerance r/t prolonged
demonstrating the first bedrest
priority nursing care CUES
plan: Subjective: Pt unable to speak c ETT.
Activity Intolerance r/t Objective: https://nurseslabs.com/category/nursing-
prolonged bed rest and - GCS : 9/15 care-plans/activityintolerance/
expected to do the - Both lower extremities were flexed with
following: resistance LEAVE IT
- ROM : 1/5 at both lower extremities BLANK
Be able to explain the - Unable to perform ADLs for 5 years
NCPs and evaluate the - Dependent on others care
progress of the - Prolonged bed rest for 5 years
objectives if goal is met - Bed sore present at left buttocks
or unmet. - Unable to sit nor walk
- Unable to communicate
Be able to identify the - Cannot maintain eye contact
objective cues OBJECTIVE
manifested by our General Objective: After 3 days of nursing intervention,
patient. the pt will be able to demonstrate an increase in activity
tolerance as evidenced by doing simple ADLs.
NURSING INTERVENTIONS & RATIONALE
Independent:
1. Monitor vital signs q1hr. To intervene
appropriate actions & monitor pt progress.
2. Assessed the physical activity level and mobility
of patient
3. Assessed ROM to all extremities
4. Elevated head of bed as tolerated
5. Turned and reposition the patient at least every 2
hours
6. Monitored VS and Regulated IVF
Dependent:
2. Notify primary healthcare when pt is not responsive
to treatment. To change treatment management.
EVALUATION
General Evaluation:
After 3days of nursing intervention patient wasn’t able to
perform require ADLs. Goal was not met
Specific Evaluation:
After 8hrs of nursing intervention pt wasn’t able to regain
muscle strength, she was lying on bed all day. Goal
wasn’t met.