ASSESSMENT NURSING OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Short Term: INDEPENDENT: Short Term:
Ineffective tissue After 4hrs nursing intervention client will be
(none) perfusion related After 4 hours of 1. Monitor Vital Signs  To obtain baseline data able to :
to decreased HgB NI, the pt will 2. Assess patient’s  demonstrated behaviours to
Objective: concentration in demonstrate condition  To assess contributing improve circulation
the blood 3. Note customary factors  demonstrated increased perfusion
behaviours to
secondary to DHF
Decreased WBC improve baseline data as appropriate
1.
circulation. 4. Determine presence  For comparison with
Decreased platelet of dysrhythmias current findings
Long Term: 5. Perform blanch test
Decreased HgB  To identify alterations from
After 4 days of NI, 6. Check for Homan’s normal
the pt will sign.
demonstrate 7. Note presence of  To identify / determine
increased bleeding adequate perfusion
perfusion as 8. Elevate HOB
appropriate 9. Encourage quiet &  To determine presence of
restful atmosphere thrombus formation
10. Instruct to avoid tiring
activities  To determine risk of anemia

 To promote circulation

 To promote comfort &

decrease tissue O2 demand

 To decrease cardiac
workload.

NURSING CARE PLAN