Assessment Diagnosis Planning Intervention Rationale Evaluation

“Nanghihina at  Impair  At the end  Frequently Early  At the

nahihilo ako ed tissue of the monitor the recognition end of
kapag tumatayo” perfusion shift, the vital signs of possible the shift,
as verbalized by related to patient adverse the
the patient. blood loss will effects patient
manifested demonstr allows for demonstr
Objective: by dizziness, ate prompt ated
 Dry Skin pale skin. adequate intervention adequate
 Restless perfusion perfusion
 Dry  Low blood and stable  Position the  To promote and
mouth pressure vital signs. patient in good stable
 Slightly due to trendelenbur circulation vital
hoarse excessive g’s. to the brain. signs.
 Low loss of
blood blood as  Administer O2
pressure evidenced inhalation.
 Pallor by pallor.
V/S taken as
follows
T=37.6
P=106
R=22
BP=110/70