St.

Paul College of Ilocos Sur

(Member: St. Paul University System)
St. Paul Avenue, 2727 Bantay, Ilocos Sur

DEPARTMENT OF NURSING

Name: Jefferson Rabino Section/Year Level: BSN ll Serviteurs Defenseurs De Saint Joseph Date: March 26, 2020

ASSESSMENT NURSING GOALS/OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective Data: Decreased cardiac  After 8 hours of
output related to nursing  Monitor blood  Comparison of After 8 hours of
“ Napansin ko na bigla decreased cardiac intervention, the pressure of the pressures provides nursing
na lang bumigat timbang output patient will patient. Measure in a more complete interventions, the
ko” as verbalized by the participate in both arms or thighs pictures of vascular patient was able
patient activities that three times, 3-5 involvement or to participate in
reduced blood minutes apart while scope of the activities that
Objective Data: pressure or patient is at rest problem. reduce blood
cardiac work load  Observe skin color,  Presence of pallor, pressure or
 Variations in cardiac work
moisture, temperature cool moist skin and
blood pressure and capillary refill time delayed capillary load.
refill time may be
 Edema due to peripheral
 V/S taken as vasoconstriction

follows:  Note dependent or  May indicate heart

general edema failure, renal or
T=37.1
vascular
PR=78 impairment
RR=20
BP=140/90

Pregnancy-Induced Hypertension, Preeclampsia, Eclampsia

 St. Paul College of Ilocos Sur
(Member: St. Paul University System)
St. Paul Avenue, 2727 Bantay, Ilocos Sur

DEPARTMENT OF NURSING

ASSESSMENT NURSING GOALS/OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective Data: Fluid volume  After 2-3 hours  Evaluate mentation  For confusion or Goal was met
excess related to of nursing personality After 2-3 hours
“ Edema grading compromised interventions, changes of nursing
edema of 2+ regulatory patient will able  Restrict Na and fluid  To emphasize interventions,
disappears 10-15 mechanism, as to verbalized dietary/fluid patient was able
intake
seconds evidenced by restriction to verbalized
understanding
tissue edema. of individual understanding
 To reduce tissue
Objective Data: dietary fluid  Advise to elevate of individual
pressure and risk
Restlessness restrictions the edematous for skin breakdown
dietary/fluid
Wt-145 lbs extremeties change restriction.
position frequently

 Stress the need for  To prevent stasis

mobility and and risk of tissue
frequent position injury
changes

Pregnancy-Induced Hypertension, Preeclampsia, Eclampsia