VII.

Laboratory Findings

Examination Done Date Results Normal Values Indication Significance or Relevance to Patient’s condition

BLOOD CHEMISTRY December 10,

2015
total cholesterol 282 mg/dL 125 to 200 mg/dL High High cholesterol levels often are a significant risk factor for coronary
artery disease.
triglycerides 145 mg/dL Below 150mg/dL Normal The result of the triglycerides is normal

glucose 98 mg/dL 70 to 100mg/dL Normal The result for glucose is normal

creatinine 340mg/dL 0.84 to 1.21mg/dL High High levels of creatinine in blood and low levels in urine indicate
kidney disease or another condition that affects kidney function. 

GFR 10ml/min/1.73m2 90 to 120 ml/min/1.73m2 Below A GFR below 15 means kidney failure. If kidney failure occurs,
dialysis or a kidney transplant will be needed to survive.

INTERPRETATION:
Total Cholesterol
- Cholesterol is a waxy, fat-like substance that's found in your blood and every cell of your body. There are two main types of cholesterol: low-density lipoprotein (LDL), or "bad"
cholesterol, and high-density lipoprotein (HDL), or "good" cholesterol. A cholesterol test is a blood test that measures the amount of each type of cholesterol and certain fats in your
blood. A cholesterol test is an important tool. High cholesterol levels often are a significant risk factor for coronary artery diseas

Triglycerides
- Triglycerides are a type of fat. They are the most common type of fat in your body. Triglycerides and cholesterol are different types of lipids that circulate in your blood: Triglycerides
store unused calories and provide your body with energy. Cholesterol is used to build cells and certain hormones. A triglycerides test measures the amount of a triglycerides in your
blood. The result of the triglycerides is normal
Glucose
- Blood sugar, or glucose, is the main sugar found in your blood. It comes from the food you eat, and is your body's main source of energy. Your blood carries glucose to all of your
body's cells to use for energy. A blood sugar test measures the amount of a sugar called glucose in a sample of your blood. The result for glucose is normal
Creatinine
- Creatinine is a waste product made by your muscles as part of regular, everyday activity. Normally, your kidneys filter creatinine from your blood and send it out of the body in your
urine. A creatinine test is used to see if your kidneys are working normally. In general, high levels of creatinine in blood and low levels in urine indicate kidney disease or another
condition that affects kidney function. 
GFR
- A glomerular filtration rate (GFR) is a blood test that checks how well your kidneys are working. Your kidneys have tiny filters called glomeruli. These filters help remove waste and
excess fluid from the blood. A GFR below 15 means kidney failure. If kidney failure occurs, dialysis or a kidney transplant will be needed to survive.

SIGNIFICANCE TO THE PATIENT:
- Electrocardiogram or “ECG” is an important
present with signs and symptoms of a possible
rhythm of a healthy heart. It means the
properly transmitted. normal sinus rhythm
per minute. ST-segment elevation is an
patient’s condition
EXAMINATION
diagnostic test that is used to screen patients who
ELECTRODIAGRAM (ECG) heart attack. Normal sinus rhythm is defined as the
electrical impulse from your sinus node is being
DATE: December 10, 2015 usually accompanies a heart rate of 60 to 100 beats
abnormality detected on the 12-lead ECG to the
IMPRESSION:

INTERPRETATION: ●Sinus Rhythm

- The 12-lead electrocardiogram or “ECG” is an
patients who present with signs and symptoms
Sinus rhythm refers to the rhythm of your
heart. Normal sinus rhythm is defined as the
impulse from your sinus node is being
accompanies a heart rate of 60 to 100 beats
(STEMI) is a very serious type of heart attack
the arteries that supplies oxygen and nutrient-
segment elevation is an abnormality detected
●Heart rate 68 bpm
●ST segment elevation.
ABDOMINAL ULTRASONOGRAPHY
DATE: December 10, 2015
IMPRESSION:
important diagnostic test that is used to screen
EXAMINATION
of a possible heart attack. 
heart beat, determined by the sinus node of your
rhythm of a healthy heart. It means the electrical
properly transmitted. normal sinus rhythm usually
per minute. ST-Elevation Myocardial Infarction
during which one of the heart’s major arteries (one of
rich blood to the heart muscle) is blocked. ST-
on the 12-lead ECG.

● neither liver nor splenic or pancreatic changes

● The kidneys had reduced size (right, 6x4x3 cm, and left, 7x4x3
cm)
● decreased corticomedullary ratio
● increased echogenicity
SIGNIFICANCE TO THE PATIENT:
- Abdominal ultrasound is used to look at organs in the abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys of the patient. The result shows liver nor splenic or
pancreatic changes. The kidneys had reduced size from 10 to 12 cm (about 5 inches), decreased corticomedullary ratio and increased echogenicity. Increased echogenicity of
the kidney parenchyma results from the increased presence of material that can reflect sound waves back, thus increasing its brightness on the ultrasonography image to the patient
condition.

INTERPRETATION:
- Abdominal ultrasound is a type of imaging test. It is used to look at organs in the abdomen, including the liver, gallbladder, spleen, pancreas, and kidneys. The result shows liver nor
splenic or pancreatic changes. Normally, kidneys are about the size of a fist or 10 to 12 cm (about 5 inches) but the result in ultrasound shows that the kidneys had reduced size.
decreased corticomedullary ratio and increased echogenicity. Echogenicity is a measure of
EXAMINATION
acoustic reflectance. Increased echogenicity of the kidney parenchyma results from
the increased presence of material that can reflect sound waves back, thus increasing its
brightness on the ultrasonography image.
CORONARY ANGIOGRAPHY
DATE: December 12, 2015

IMPRESSION:

● right coronary occlusion

●70% lesion in the middle portion of the anterior interventricular
branch of the left coronary artery
●70% lesion in the first diagonal branch and irregularities in the
circumflex branch
SIGNIFICANCE OF THE PATIENT:
A coronary angiogram is a procedure that uses X-ray imaging to see patient heart's blood vessels. The test is generally done to see if there's a restriction in blood flow going to the heart.
An occlusion is a complete or partial blockage of a blood vessel. While occlusions can happen in both veins and arteries, the more serious ones occur in the arteries.
An occlusion can reduce or even stop the flow of oxygen-rich blood to downstream vital tissues like the heart, brain, or extremities.

INTERPRETATION:
A coronary angiogram is a procedure that uses X-ray imaging to see your heart's blood vessels. The test is generally done to see if there's a restriction in blood flow going to the heart. A
coronary angiogram, which can help diagnose heart conditions, is the most common type of cardiac catheterization procedure. The right coronary artery supplies blood to the right
ventricle, the right atrium, and the SA (sinoatrial) and AV (atrioventricular) nodes, which regulate the heart rhythm. An occlusion is a complete or partial blockage of a blood
vessel. While occlusions can happen in both veins and arteries, the more serious ones occur in the arteries. An occlusion can reduce or even stop the flow of oxygen
rich blood to downstream vital tissues like the heart, brain, or extremities.

Examination Done Date Results Normal Values Indication Significance or Relevance to Patient’s condition
COMPLETE BLOOD December 22,
COUNT 2015
8.3 g/dL 13.5 to 17.5 g/dL Low A low hemoglobin count that's more severe and causes symptoms
Hemoglobin might mean you have anemia. If you have anemia, your cells
don't get all the oxygen they need. 

red blood cell count 27% 40 - 55% Low A lower than normal hematocrit can indicate of an insufficient
supply of healthy red blood cells

platelets 438,000 150,000 to 400,000 High If your blood has too many platelets, you may have a higher risk
of blood clots

leukocytes: 10,900/mm3 5,000 to 10,000/mm3 High higher than normal may mean that you have an infection or
illness that your body is fighting

neutrophils 79% 40% to 60% High High percentage of neutrophils in your blood is called
neutrophilia. This is a sign that your body has an infection. 

eosinophils 2% 1% to 4% Normal The Result for Eosinophils is normal

lymphocytes 11% 20% to 40% Low Below the normal range can also be temporary. They can occur
after a cold or another infection, or be caused by intense physical
exercise, severe stress, or malnutrition.

monocytes 8% 2% to 8% Normal The monocytes result is normal

INTERPRETATION:

Hemoglobin
- Hemoglobin is a protein in your red blood cells that carries oxygen from your lungs to the rest of your body. A hemoglobin test measures the levels of hemoglobin in your blood also
often used to check for anemia, a condition in which your body has fewer red blood cells than normal. A low hemoglobin count that's more severe and causes symptoms might mean you
have anemia. If you have anemia, your cells don't get all the oxygen they need. 
Red Blood Cell Count
- Red blood cells carry oxygen throughout your body. A hematocrit test measures the proportion of red blood cells in your blood. A lower than normal hematocrit can
indicate of an insufficient supply of healthy red blood cells (anemia)

Platelets
- Platelets, also known as thrombocytes, are blood cells. Platelets play a major role in blood clotting. Normally, when one of your blood vessels is injured, you start to bleed. Your platelets will
clot (clump together) to plug the hole in the blood vessel and stop the bleeding. If your blood has too many platelets, you may have a higher risk of blood clots.

Leukocytes
- WBCs are also called leukocytes. They help fight infections. A WBC count is a blood test to measure the number of white blood cells (WBCs) in the blood. Test results that are higher
than normal may mean that you have an infection or illness that your body is fighting.
Neutrophils
- Neutrophils are the primary white blood cells that respond to a bacterial infection. The most common cause of marked neutrophilia is a bacterial infection. Having a high percentage of
neutrophils in your blood is called neutrophilia. This is a sign that your body has an infection. 
Eosinophils
- Eosinophils are a type of disease-fighting white blood cell. This condition most often indicates a parasitic infection, an allergic reaction or cancer. The Eosinophils is
normal
Lymphocytes
- Lymphocytes are white blood cells that plays several roles in the immune system, including protection against bacteria, viruses, fungi, and parasites A low level can also be a sign of a
condition known as lymphocytopenia or lymphopenia. Lymphocyte counts below the normal range can also be temporary. They can occur after a cold or another infection, or be caused
by intense physical exercise, severe stress, or malnutrition.
Monocytes
- Monocytes are the largest type of white blood cell. Monocytes protect against viral, bacterial, fungal, and protozoal infections. They kill microorganisms, ingest foreign particles,
remove dead cells, and boost the immune response. The monocytes result is normal
 Examination Done Date Results Normal Values Indication Significance or Relevance to Patient’s condition

BLOOD CHEMISTRY December 22,

2015

Creatinine 5.6 mg/dL 0.84 to 1.21 mg/dL High high levels of creatinine in blood and low levels in urine
indicate kidney disease or another condition that affects
kidney function. 

Urea 76 mg/dL 7 to 20 mg/dL High Higher than normal BUN levels may be a sign that your
kidneys aren't working efficiently.

INTERPRETATION:
Creatinine
- Creatinine is a waste product made by your muscles as part of regular, everyday activity. Normally, your kidneys filter creatinine from your blood and send it out of the body in your
urine. A creatinine test is used to see if your kidneys are working normally. In general, high levels of creatinine in blood and low levels in urine indicate kidney disease or another
condition that affects kidney function. 
Urea
- A BUN, or blood urea nitrogen test, can provide important information about your kidney function. The main job of your kidneys is to remove waste and extra fluid from your body.
The test measures the amount of urea nitrogen in your blood. Urea nitrogen is one of the waste
products removed from your blood by your EXAMINATION kidneys. Higher than normal BUN levels may be a
sign that your kidneys aren't working efficiently.

ELECTRODIAGRAM (ECG)

DATE: December 22, 2015

IMPRESSION:

●Sinus rhythm
●heart rate 78 bpm
●PR interval 168ms
●QRS length 111ms
●QT interval 428ms
●low QRS complex voltage in the frontal plane
●electrically inactive region in the inferodorsal wall
SIGNIFICANCE TO THE PATIENT:
- 12-lead electrocardiogram or “ECG” is an important diagnostic test that is used to screen patients who present with signs and symptoms of a possible heart attack. Normal sinus rhythm
is defined as the rhythm of a healthy heart. It means the electrical impulse from your sinus node is being properly transmitted. normal sinus rhythm usually accompanies a heart rate of
60 to 100 beats per minute. PR interval is the time from the onset of the P wave to the start of the QRS complex. A combination of the Q wave, R wave and S wave, are the “QRS
complex” represents ventricular depolarization. QT interval is the time from the start of the Q wave to the end of the T wave. It represents the time taken for ventricular depolarization
and repolarization, effectively the period of ventricular systole from ventricular isovolumetric contraction to isovolumetric relaxation.

INTERPRETATION:
- The 12-lead electrocardiogram or “ECG” is an important diagnostic test that is used to screen patients who present with signs and symptoms of a possible heart attack.  Sinus rhythm
refers to the rhythm of your heart beat, determined by the sinus node of your heart. Normal sinus rhythm is defined as the rhythm of a healthy heart. It means the electrical impulse from
your sinus node is being properly transmitted. normal sinus rhythm usually accompanies a heart rate of 60 to 100 beats per minute. The  PR interval is the time from the onset of the P
wave to the start of the QRS complex. It reflects conduction through the AV node. The result of PR interval 168ms and the normal PR interval is between 120 – 200ms. A combination
of the Q wave, R wave and S wave, the “QRS complex” represents ventricular depolarization. Normal QRS width is 70-100ms but the result shows, QRS length 111ms. Broad
complexes (QRS > 100ms) may be either ventricular in origin, or due to aberrant conduction of supraventricular complexes. QT interval is the time from the start of the Q wave to
the end of the T wave. It represents the time taken for ventricular depolarization and repolarization, effectively the period of ventricular systole from ventricular isovolumetric
contraction to isovolumetric relaxation. QTc is prolonged if > 440ms and the result shows QT interval 428ms. Low QRS complex voltage in the frontal plane and electrically inactive
region in the inferodorsal wall.
-
 EXAMINATION

CHEST RADIOGRAPHY

DATE: December 23, 2015

RESULT:

● mediastinal enlargement
●pulmonary opacification at the right base and
marked pulmonary congestion.

SIGNIFICANCE TO THE PATIENT:

- Chest x-ray uses a very small dose of ionizing radiation to produce pictures of the inside of the chest. is used to evaluate the lungs, heart and chest wall and may be used to help diagnose
shortness of breath of the patient. Enlarged vessels such as thoracic aortic aneurysms or congenital vascular anomalies may also cause mediastinal enlargement. Pulmonary
opacification represents the result of a decrease in the ratio of gas in the right lung leading to accumulation of fluid in the lungs, may resulting in impaired gas exchange

INTERPRETATION:

- Chest x-ray uses a very small dose of ionizing radiation to produce pictures of the inside of the chest. It is used to evaluate the lungs, heart and chest wall and may be used to help
diagnose shortness of breath. Enlarged vessels such as thoracic aortic aneurysms or congenital vascular anomalies may also cause mediastinal enlargement. Pulmonary
opacification represents the result of a decrease in the ratio of gas to soft tissue (blood, lung parenchyma and stroma) in the lung. Pulmonary congestion is defined as accumulation of
fluid in the lungs, resulting in impaired gas exchange and arterial hypoxemia
 EXAMINATION

MAGNETIC RESONANCE IMAGING (MRI)

DATE: December 12, 2015

IMPRESSION:

●dissection from the thoracic aorta to its bifurcation (beginning of the

iliac arteries), with diameter ranging from 32 mm in the suprarenal
region to 22 mm in the infrarenal region.
●The right renal artery emerged from the false lumen, while the left
renal artery emerged from the true lumen, and both were occluded.
●In addition, the left common iliac was occluded, being filled through
collateral circulation.

SIGNIFICANCE OF THE PATIENT:

- Magnetic resonance imaging (MRI) of the body uses a powerful magnetic field, radio waves and a computer to produce detailed pictures of the inside of your body. Aortic dissection is
a serious condition in which there is a tear in the wall of the major artery carrying blood out of the heart (aorta). The normal lumen lined by intima is called the true lumen and the
blood-filled channel in the media is called the false lumen and both Right renal artery and Left renal artery were occluded. When the coronary arteries narrow to the point that
blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and become active
INTERPRETATION:
- Magnetic resonance imaging (MRI) of the body uses a powerful magnetic field, radio waves and a computer to produce detailed pictures of the inside of your body. It may be used to
help diagnose or monitor treatment for a variety of conditions within the chest, abdomen and pelvis. Aortic dissection is a serious condition in which there is a tear in the wall of the
major artery carrying blood out of the heart (aorta). As the tear extends along the wall of the aorta, blood can flow in between the layers of the blood vessel wall (dissection). The normal
lumen lined by intima is called the true lumen and the blood-filled channel in the media is called the false lumen. Collateral circulation is a network of tiny blood vessels, and, under
normal conditions, not open. When the coronary arteries narrow to the point that blood flow to the heart muscle is limited (coronary artery disease), collateral vessels may enlarge and
become active.
 Examination Done Date Results Normal Values Indication Significance or Relevance to Patient’s condition

COMPLETE BLOOD December 26,

COUNT 2015

Hemoglobin 8.3 g/dL 13.8 to 17.2 g/dL Low A low hemoglobin count that's more severe and
causes symptoms might mean you have anemia. If
you have anemia, your cells don't get all the oxygen
they need. 

red blood cell count 27% 38.3 to 48.6% Low A lower than normal hematocrit can indicate of an
insufficient supply of healthy red blood cells

platelets 483,000/mm3 150,000 to 350,000 High If your blood has too many platelets, you may have a
higher risk of blood clots

leukocytes: 8,000/mm3 4500 to 11,000 Normal The Result for leukocytes is normal

neutrophils 71% 40% to 60% High High percentage of neutrophils in your blood is called
neutrophilia. This is a sign that your body has an
infection. 
eosinophils 3% 1% to 4% Normal
The Result for Eosinophils is normal

lymphocytes 20% 20% to 40% Normal The Result for Lymphocytes is normal

Normal The monocytes result is normal

monocytes 6% 2% to 8%

INTERPRETATION:
Hemoglobin
- Hemoglobin is a protein in your red blood cells that carries oxygen from your lungs to the rest of your body. A hemoglobin test measures the levels of hemoglobin in your blood also
often used to check for anemia, a condition in which your body has fewer red blood cells than normal. A low hemoglobin count that's more severe and causes symptoms might mean you
have anemia. If you have anemia, your cells don't get all the oxygen they need. 

Red Blood Cell Count

- Red blood cells carry oxygen throughout your body. A hematocrit test measures the proportion of red blood cells in your blood. A lower than normal hematocrit can
indicate of an insufficient supply of healthy red blood cells (anemia)

Platelets
- Platelets, also known as thrombocytes, are blood cells. Platelets play a major role in blood clotting. Normally, when one of your blood vessels is injured, you start to bleed. Your platelets will
clot (clump together) to plug the hole in the blood vessel and stop the bleeding. If your blood has too many platelets, you may have a higher risk of blood clots.

Leukocytes
- WBCs are also called leukocytes. They help fight infections. A WBC count is a blood test to measure the number of white blood cells (WBCs) in the blood. The result for leukocytes is
normal
Neutrophils
- Neutrophils are the primary white blood cells that respond to a bacterial infection. The most common cause of marked neutrophilia is a bacterial infection. Having a high percentage of
neutrophils in your blood is called neutrophilia. This is a sign that your body has an infection. 
Eosinophils
- Eosinophils are a type of disease-fighting white blood cell. This condition most often indicates a parasitic infection, an allergic reaction or cancer. The Eosinophils is
normal
Lymphocytes
- Lymphocytes are white blood cells that plays several roles in the immune system, including protection against bacteria, viruses, fungi, and parasites The Result for Lymphocytes is
normal
Monocytes
- Monocytes are the largest type of white blood cell. Monocytes protect against viral, bacterial, fungal, and protozoal infections. They kill microorganisms, ingest foreign particles,
remove dead cells, and boost the immune response. The monocytes result is normal
 Examination Done Date Results Normal Values Indication Significance or Relevance to Patient’s condition

BLOOD CHEMISTRY December 22,

2015

Creatinine 4.5 mg/dL 0.84 to 1.21 mg/dL High high levels of creatinine in blood and low levels in urine
indicate kidney disease or another condition that affects
kidney function. 

Urea 60 mg/dL 7 to 20 mg/dL High Higher than normal BUN levels may be a sign that your
kidneys aren't working efficiently.

Potassium 4mEq/L 3.5 to 5.5mEq/L Normal The Result for potassium is normal

sodium 131mEq/L 135 to 145mEq/L Low Lower than normal sodium levels, it may indicate Kidney
(Hyponatremia) disease or Heart failure
INTERPRETATION:
Creatinine
- Creatinine is a waste product made by your muscles as part of regular, everyday activity. Normally, your kidneys filter creatinine from your blood and send it out of the body in your
urine. A creatinine test is used to see if your kidneys are working normally. In general, high levels of creatinine in blood and low levels in urine indicate kidney disease or another
condition that affects kidney function. 

Urea
- A BUN, or blood urea nitrogen test, can provide important information about your kidney function. The main job of your kidneys is to remove waste and extra fluid from your body.
The test measures the amount of urea nitrogen in your blood. Urea nitrogen is one of the waste products removed from your blood by your kidneys. Higher than normal BUN levels may
be a sign that your kidneys aren't working efficiently.

Potassium
- Potassium is a mineral that your body needs to work properly. It is a type of electrolyte. It helps your nerves to function and muscles to contract. It helps your heartbeat stay regular. It
also helps move nutrients into cells and waste products out of cells. The Result for potassium is normal
Sodium
- Sodium is a type of electrolyte. Electrolytes are electrically charged minerals that help maintain fluid levels and the balance of chemicals in your body called acids and bases. Sodium
also helps your nerves and muscles work properly. A sodium blood test measures the amount of sodium in your blood. Low blood sodium is a condition in which the amount of sodium
in the blood is lower than normal. The medical name of this condition is hyponatremia. Lower than normal sodium levels, it may indicate Kidney disease or Heart failure

EXAMINATION

HEMODIALYSIS

DATE: December 27, 2015

INTERPRETATION:
- Hemodialysis is a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean the blood. To get the blood into the dialyzer, the
doctor needs to make an access, or entrance, into the blood vessels.
 VIII. NURSING CARE PLAN

Problem and Cues Nursing Diagnosis / Planning/Objective Nursing Interventions Rationale Evaluation
(Assessment) Scientific Rationale

Objective: Short term goal: Independent: After the intervention, the goal is partially met.
Vital Signs: Ineffective Breathing Pattern After 1-3 hours of  Evaluate respiratory  Client responses are  Patient maintains an effective breathing
 BP: 170/80 Related to Musculoskeletal nursing intervention: rate and depth. variable. Rate and pattern, as evidenced by relaxed
 T: 37 Impairment  Patient will Note respiratory effort may be breathing at normal rate and depth and
 P: 95 indicate, effort; for example, increased by pain, absence of dyspnea.
 R: 28 and laboured either verbally presence of fear, fever,  Patient’s respiratory rate remains
 Dyspnea or through dyspnea, use of diminished within established limits.
 Cough behavior, accessory muscles, circulating volume  Patient indicates, either verbally or
CHEST RADIOGRAPHY feeling and nasal flaring. due to blood or through behavior, feeling comfortable
RESULT: comfortable fluid loss, when breathing.
● mediastinal enlargement when accumulation of  Patient reports feeling rested each day.
●pulmonary opacification breathing. secretions, hypoxia,  Patient performs diaphragmatic pursed-
at the right base and  Patient will orgastric distention. lip breathing.
Marked pulmonary report feeling Respiratory  -Patient demonstrates maximum lung
congestion. rested each suppression can expansion with adequate ventilation.
day. occur from long  When patient carries out ADLs,
 Patient will time period under breathing pattern remains normal.
perform anesthesia or heavy
diaphragmatic use of opioid
pursed-lip analgesics. Early
 breathing. recognition and
Long term goal: treatment of
After 2-3 days of abnormal
nursing intervention: ventilation may
 Patient will prevent
maintains an complications.
effective
breathing  Place patient with  A sitting position
pattern, as proper body permits maximum
evidenced by alignment for lung excursion and
relaxed maximum breathing chest expansion.
breathing at pattern.
normal rate
and depth and  Encourage  These techniques
absence of sustained deep promote deep
dyspnea. breaths by: inspiration, which
 Patient’s - Using demonstration: increases
respiratory highlighting slow oxygenation and
rate will inhalation, holding end prevents atelectasis.
remains inspiration for a few Controlled
within seconds, and passive breathing methods
established exhalation may also aid slow
limits. - Utilizing incentive respirations in
 Patient will spirometer patients who are
demonstrate - Requiring the patient to tachypneic.
maximum yawn Prolonged
lung expiration prevents
expansion air trapping.
with adequate
ventilation.  Encourage  This method
 When patient diaphragmatic relaxes muscles and
carries out breathing for increases the
ADLs, patients with patient’s oxygen
breathing chronic disease. level.
pattern will
remains  Evaluate the  This training
normal. appropriateness of improves conscious
inspiratory muscle control of
 training. respiratory muscles
and inspiratory
muscle strength.

 Stay with the  This will reduce the

patient during acute patient’s anxiety,
episodes of thereby reducing
respiratory distress. oxygen demand.

 Encourage frequent  Extra activity can

rest periods and worsen shortness of
teach patient to breath. Ensure the
pace activity. patient rests
between strenuous
activities.

 Consult dietitian for  Good nutrition can

dietary strengthen the
modifications. functionality of
respiratory muscles.

 Encourage small  This prevents

frequent meals. crowding of the
diaphragm.

 Help patient with  This conserves

ADLs, as energy and avoids
necessary. overexertion and
fatigue.

 Avail a fan in the  Moving air can

room. decrease feelings of
air hunger.

 Teach patient  These measures

about: allow patient to
- pursed-lip breathing participate in
- abdominal breathing maintaining health
- performing relaxation status and improve
techniques ventilation.
- performing relaxation
techniques
- taking prescribed
medications (ensuring
accuracy of dose and
frequency and monitoring
adverse effects)
- scheduling activities to
avoid fatigue and provide
for rest periods
 Problem and Cues Nursing Diagnosis / Planning/Objective Nursing Interventions Rationale Evaluation
(Assessment) Scientific Rationale

Objective: Impaired Gas Exchange Short term goal: Independent: After the intervention, the goal is partially
Vital Signs: Related to Altered Oxygen- After 2-3 hours of  Note respiratory  Dyspnea and met.
BP:170/80 Carrying Capacity of Blood nursing intervention: rate and depth and increased work of  Patient maintains optimal gas
T: 38.5 and Infection work of breathing, breathing may be exchange as evidenced by
R: 28 and laboured  Patient will such as use of first or only sign of unlabored respirations at 12-20 per
Dyspnea verbalizes accessory muscles subacute pulmonary minute, oximetry results within
COMPLETE BLOOD understanding or nasal flaring and embolism. Severe normal range, blood gases within
COUNT of oxygen and pursed-lip respiratory distress normal range, and baseline HR for
 Hemoglobin other breathing. and failure patient.
(decreased) therapeutic accompanies  Patient maintains clear lung fields
8.3 g/dL interventions. moderate to severe and remains free of signs of
 Patient will loss of functional respiratory distress.
 red blood cell participates in lung units.  Patient verbalizes understanding of
count (decreased) procedures to  Auscultate lungs oxygen and other therapeutic
27% optimize for areas of  Nonventilated areas interventions.
oxygenation decreased and may be identified  Patient participates in procedures to
 leukocytes: and in absent breath by absence of optimize oxygenation and in
(elevated) management sounds and the breath sounds. management regimen within level
10,900/mm3 regimen within presence of Crackles occur in of capability/condition
level of adventitious fluid-filled tissues  Patient manifests resolution or
capability/condi sounds, such as and airways or may absence of symptoms of respiratory
 tion crackles reflect cardiac distress
Long term goal: decompensation.
After 2-3 days of  Position patient
nursing intervention: with head of bed  Upright position or
 Patient will elevated, in a semi- semi-Fowler’s
maintain Fowler’s position position allows
optimal gas (head of bed at 45 increased thoracic
exchange as degrees when capacity, full
evidenced by supine) as tolerated. descent of
unlabored diaphragm, and
respirations at increased lung
12-20 per expansion
minute, preventing the
oximetry results abdominal contents
within normal from crowding.
range, blood  Regularly check the
gases within patient’s position so  Slumped
normal range, that he or she does positioning causes
and baseline not slump down in the abdomen to
HR for patient. bed. compress the
 Patient will diaphragm and
maintains clear limits full lung
lung fields and expansion
remains free of  If patient has
signs of unilateral lung  Gravity and
respiratory disease, position the hydrostatic pressure
distress. patient properly to cause the dependent
 Patient will promote lung to become
manifests ventilation- better ventilated
resolution or perfusion. and perfused, which
absence of increases
symptoms of oxygenation. When
respiratory the patient is
distress positioned on the
side, the good side
should be down
(e.g., lung with
pulmonary embolus
 or atelectasis
should be up).
However, when
conditions like lung
hemorrhage and
abscess is present,
the affected lung
should be placed
downward to
prevent drainage to
the healthy lung.
 Turn the patient
every 2 hours.  Turning is
Monitor mixed important to
venous oxygen prevent
saturation closely complications of
after turning. If it immobility, but in
drops below 10% or critically ill patients
fails to return to with low
baseline promptly, hemoglobin levels
turn the patient or decreased
back into a supine cardiac output,
position and turning on either
evaluate oxygen side can result in
status. desaturation.

 Patient is obese and

has ascites,  Trendelenburg
consider position at 45
positioning in degrees results in
reverse increased tidal
Trendelenburg volumes and
position at 45 decreased
degrees for periods respiratory rates.
as tolerated.

 Consider
positioning the  Partial pressure of
 patient prone with arterial oxygen has
upper thorax and been shown to
pelvis supported, increase in the
allowing the prone position,
abdomen to possibly because of
protrude. Monitor greater contraction
oxygen saturation, of the diaphragm
and turn back if and increased
desaturation occurs. function of ventral
Do not put in prone lung regions. Prone
position if patient positioning
has multisystem improves
trauma. hypoxemia
significantly.
 If patient is acutely
dyspneic, consider  Leaning forward
having patient lean can help decrease
forward over a dyspnea, possibly
bedside table, if because gastric
tolerated. pressure allows
better contraction
of the diaphragm.
 Provide reassurance
and reduce anxiety.  Anxiety increases
dyspnea,
respiratory rate, and
work of breathing.
 Pace activities and
schedule rest  Activities will
periods to prevent increase oxygen
fatigue. Assist with consumption and
ADLs. should be planned
so the patient does
not become
Dependent: hypoxic.
 Administer
medications as
prescribed
 -Cefriaxone  Therapeutic Effect:
Bactericidal

- Acetylsalicylic  Therapeutic Effect:

acid 100 mg Reduces
inflammatory
response

Problem and Cues Nursing Diagnosis / Planning/Objective Nursing Interventions Rationale Evaluation
(Assessment) Scientific Rationale

Subjective:
 The patient had Decreased Cardiac Output
noted a 30 pound
weight gain over
the past month
Objective:
 Vital Signs:
BP:170/80
T: 38.5
R: 28 and laboured
 Dyspnea
 Rales
 Abnormal heart
sounds (S3, S4)
 Edema
Coronary Angiography,
which revealed right
coronary occlusion,
•70% lesion in the middle
portion of the anterior
interventricular branch of
Short term goal: Independent: After the intervention, the goal is partially
Related to Impaired After 2-3 hours of  Monitor BP and  Fluid volume met.
Contractility nursing intervention: heart rate. excess, combined  Patient demonstrates adequate cardiac
 Patient will with hypertension, output as evidenced by blood pressure
explain which often occurs and pulse rate and rhythm within
actions and in renal failure, and normal parameters for patient; strong
precautions to effects of uremia peripheral pulses; and an ability to
take for increase cardiac tolerate activity without symptoms of
cardiac workload and can dyspnea, syncope, or chest pain.
disease. lead to cardiac  Patient exhibits warm, dry skin,
Long term goal: failure. In AKI, eupnea with absence of pulmonary
After 2-3 days of cardiac failure is crackles.
nursing intervention: usually reversible.  Patient remains free of side effects
 Patient will from the medications used to achieve
demonstrates  Observe ECG or  Changes in adequate cardiac output.
adequate telemetry for electromechanical  Patient explains actions and
cardiac output changes in rhythm. function may precautions to take for cardiac disease.
as evidenced become evident in
by blood response to
pressure and accumulation of
the left coronary artery, pulse rate and toxins and
•70% lesion in the first rhythm within electrolyte
diagonal branch and normal imbalance.
irregularities in the parameters for
circumflex branch. patient; strong  Auscultate heart  Development of
peripheral sounds. S3/S4 is associated
pulses; and an with fluid volume
ability to excess and
tolerate congestive HF.
activity Pericardial friction
without rub may be only
symptoms of manifestation of
dyspnea, uremic pericarditis,
syncope, or requiring prompt
chest pain. intervention and,
 Patient will possibly, acute
exhibits dialysis.
warm, dry
skin, eupnea  Assess color of  Pallor may reflect
with absence skin, mucous vasoconstriction or
of pulmonary membranes, and anemia—common
crackles. nailbeds. Note in AKI, whether
 Patient will capillary refill time. associated with
remains free actual blood loss or
of side effects abnormalities in life
from the of RBCs. Cyanosis
medications is a late sign and is
used to related to
achieve pulmonary
adequate congestion or
cardiac cardiac failure. A
output. long capillary refill
time is associated
with hypovolemic
states.

 Record intake and  Reduced cardiac

output. If patient is output results in
 acutely ill, measure reduced perfusion
hourly urine output of the kidneys, with
and note decreases a resulting decrease
in output. in urine output

 Closely monitor for  As these symptoms

symptoms of heart of heart failure
failure and progress, cardiac
decreased cardiac output declines.
output, including
diminished quality
of peripheral
pulses, cold and
clammy skin and
extremities,
increased
respiratory rate,
presence of
paroxysmal
nocturnal dyspnea
or orthopnea,
increased heart rate,
neck vein
distention,
decreased level of
consciousness, and
presence of edema.

 Monitor laboratory  Routine blood work

tests such as can provide insight
complete blood into the etiology of
count, sodium heart failure and
level, and serum extent of
creatinine. decompensation. A
low serum sodium
level often is
observed with
advanced heart

 Administer  Depending on
medications as
prescribed, noting
side effects and
toxicity.
Maintain adequate
ventilation and perfusion as
in the following:
 Position patient in  Upright position is
semi-Fowler’s to
high-Fowler’s.
 Place patient in  For hypovolemia,
failure and can be a
poor prognostic
sign. Serum
creatinine levels
will elevate in
patients with severe
heart failure
because of
decreased perfusion
to the kidneys.
Creatinine may also
elevate because of
ACE inhibitors
etiological factors,
common
medications include
digitalis
therapy,diuretics,
vasodilator therapy,
antidysrhythmics,
angiotensin-
converting enzyme
inhibitors, and
inotropic agents.
recommended to
reduce preload and
ventricular filling
when fluid overload
is the cause.
 supine position supine positioning
increases venous
return and promote
diuresis.

 Educate family and  Early recognition of

patient about the symptoms
disease process, facilitates early
complications of problem solving
disease process, and prompt
information on treatment.
medications, need
for weighing daily,
and when it is
appropriate to call
doctor.

 Aid family adapts  Transition to the

daily living patterns home setting can
to establish life cause risk factors
changes that will such as
maintain improved inappropriate diet
cardiac functioning to reemerge.
in the patient.

Dependent:
 Administer
medications as
prescribed

 Furosemide  Therapeutic Effect:

Diuretic 20mg Produces diuresis
lowers B/P.

 Isosorbide  Therapeutic Effect:

mononitrate Relaxes vascular
Antianginal 40 mg smooth muscle of
 arterial, venous
vasculature.
 Atenolol
Antihypertensive,  Therapeutic Effect:
Antianginal 50mg Slows sinus node
heart rate,
decreasing B/P
 Amlodipine
Antihypertensive,  Therapeutic Effect:
Antianginal 100 mg Dilates coronary
arteries, peripheral
arteries/arterioles.
Decreases total
peripheral vascular
resistance and B/P
by vasodilation
 Problem and Cues Nursing Diagnosis / Planning/Objective Nursing Interventions Rationale Evaluation
(Assessment) Scientific Rationale

Subjective:
 The patient had Short term goal: Independent: After the intervention, the goal is partially
noted a 30 pound Excess Fluid Volume After 2-3 hours of met.
weight gain over Related to Renal nursing intervention:  Monitor weight regularly  Sudden weight gain  Patient is normovolemic as
the past month Insufficiency and Chronic  Patient will using the same scale and may mean fluid evidenced by urine output greater
Objective: Heart Disease verbalizes preferably at the same time of retention. Different than or equal to 30 mL/hr.
 Vital Signs: awareness of day wearing the same amount scales and clothing  Patient has balanced intake and
BP:170/80 causative of clothing. may show false weight output and stable weight.
T: 38.5 factors and inconsistencies.  Patient has clear lung sounds as
R: 28 and laboured behaviors manifested by absence of
 Dyspnea essential to  Monitor input and output  Dehydration may be pulmonary crackles.
 Rales correct fluid closely. the result of fluid  Patient verbalizes awareness of
 S3 excess. shifting even if overall causative factors and behaviors
 Abdomen was  Patient will fluid intake is essential to correct fluid excess.
enlarged with a explain adequate.  Patient explains measures that can
positive fluid measures that be taken to treat or prevent fluid
wave. can be taken  Assess weight in relation to  In some patient with volume excess.
 Edema to treat or nutritional status. heart failure, the  Patient describes symptoms that
 Oliguria prevent fluid weight may be a poor indicate the need to consult with
BLOOD CHEMISTRY volume indicator of fluid health care provider
excess. volume status. Poor
Creatinine (elevated)  Patient will nutrition and
5.6 mg/dL describes decreased appetite
symptoms over time result in a
Urea(elevated) that indicate decrease in weight,
76 mg/dL the need to which may be
 consult with accompanied by fluid
Sodium(decreased) health care retention even though
131mEq/L provider the net weight remains
Long term goal: unchanged.
After 2-3 days of
nursing intervention:  Assess urine output in  Recording two voids
 Patient will response to diuretic therapy. versus six voids after a
COMPLETE BLOOD normovolemi diuretic medication
COUNT c as may provide more
evidenced by useful information.
Hemoglobin(decreased) urine output Medications may be
8.3 g/dL greater than given intravenously
or equal to 30 because FVE in the
mL/hr. abdomen may interfere
 Patient will with absorption of oral
red blood cell have balance diuretic medications.
count(decreased) intake and
27% output and  Monitor and note BP and HR.  Sinus tachycardia and
stable weight. increased BP are
 Patient will evident in early stages
have clear
lung sounds  Monitor fluid intake  This enhances
as manifested compliance with the
by absence of regimen.
pulmonary
crackles.  Take diuretics as prescribed.  Diuretics aids in the
excretion of excess
body fluids.

 Elevate edematous  Elevation increases

extremities, and handle with venous return to the
care. heart and, in turn,
decreases edema.
Edematous skin is
more susceptible to
injury.

 Place the patient in a semi-  Raising the head of

 Fowler’s or high-Fowler’s bed provides comfort
position. in breathing

 Educate patient and family  Knowledge heightens

members the importance of compliance with the
proper nutrition, hydration, treatment plan.
and diet modification.

Dependent:
 Administer medications as
prescribed to treat underlying
problem. Note the response.

Generic Name:  Diuretics aids in the

Furosemide 20mg excretion of excess
Diuretic. body fluids.
 Problem and Cues Nursing Diagnosis / Planning/Objective Nursing Interventions Rationale Evaluation
(Assessment) Scientific Rationale

Objective: Independent:
 Vital Signs: Short term goal:  Monitor the patient’s HR, BP,  HR and BP increase as After the intervention, the goal is
BP:170/80 Hyperthermia Related to After 4-8 hours of and especially the tympanic hyperthermia partially met.
T: 38.5 Infection of the trachea nursing intervention: or rectal temperature. progresses. Tympanic  Patient maintains body
R: 28 and laboured  Patient will or rectal temperature temperature below 39° C (102.2°
 Dyspnea maintains gives a more accurate F).
 Rales body indication of core  Patient maintains BP within
temperature temperature. normal limits
COMPLETE BLOOD below 39° C
COUNT (102.2° F).  Determine the patient’s age  Extremes of age or
 Patient will and weight. weight increase the
leukocytes: (elevated) maintain BP risk for the inability to
within normal control body
10,900/mm3 limits. temperature.

neutrophils(elevated)  Adjust and monitor  Room temperature

79% environmental factors like
room temperature and bed
linens as indicated.
may be accustomed to
near normal body
temperature and
blankets and linens
may be adjusted as
indicated to regulate
temperature of the
patient.

 Eliminate excess clothing and  Exposing skin to room

covers. air decreases warmth

 Noninvasive: cooling
mattress, cold packs applied
to major blood vessels
 Evaporative cooling: cool
with a tepid bath; do not use
alcohol
 Modify cooling measures
based on the patient’s
physical response.
 Raise the side rails at all
times.
Dependent:
 Administer medications as
prescribed to treat underlying
problem. Note the response.
Generic Name:
 acetylsalicylic acid
Anti-inflammatory,
antipyretic, anticoagulant.
100 mg
and increases
evaporative cooling.
 These measures help
promote cooling and
lower core
temperature.
 Alcohol cools the skin
too rapidly, causing
shivering.
 Cooling too quickly
may cause shivering,
which increases the
use of energy calories
and increases the
metabolic rate to
produce heat.
 This is to ensure
patient’s safety even
without the presence
of seizure activity.
 Therapeutic Effect:
Reduces
inflammatory
response, intensity
of pain; decreases
fever; inhibits
platelet
 aggregation
Generic Name: 
 Ceftriaxone  Therapeutic Effect:
Antibiotic Bactericidal

Problem and Cues Nursing Diagnosis / Planning/Objective Nursing Interventions Rationale Evaluation
(Assessment) Scientific Rationale

Objective: Imbalance Diet More than Short term goal: Independent After the intervention, the goal was
 The patient had Body Requirement After 8hrs of nursing partially met.
noted a 30 pound intervention:  Explain to the  It will give a better  Patient was able to verbalizes
weight gain over patient and understanding on accurate information about benefits
the past month  Patient will be significant others the need of meeting of weight loss.
 Anthropometric able to verbalises the importance the daily nutritional  Patient was able to states related
Measures: accurate of maintaining requirements of the factors contributing to weight gain.
Body Weight: information proper nutrition. body.
101kg about benefits of  Patient was able to design a dietary
weight loss.  Note weight and  Exact weight needs modifications to meet individual
 Patient will be calculate body to be documented, long-term goal of weight control,
able to states mass index as patient may have using principles of variety, balance,
related factors (BMI). been estimating and moderation.
contributing to over time. BMI
weight gain. describes relative
weight for height
Long term goal: and is significantly
After 3days of nursing associated with
intervention: total body fat
 Patient will be content. BMI is the
able to design a patient’s weight in
dietary kilograms divided
modifications to by the square of his
meet individual or her height in
long-term goal meters. A BMI
of weight between 20 and 24
control, using is associated with
principles of healthier outcomes.
variety, balance, BMIs greater than
and moderation. 25 are associated
with increased
morbidity and
mortality.

 Evaluate  Non dieting

patient’s approaches focus
physiological on changing
status in relation disturbed thoughts,
to weight emotions, and body
control. image associated
with obesity to help
obese persons
accept themselves
and resolve
concerns that
prevent long-term
weight
maintenance.

 Suggest patient  Self-monitoring

to keep a diary helps the patient
of food intake assess adherence to
and self-determined
circumstances performance
surrounding its criteria and
consumption progress toward
(methods of desired goals. Self-
preparation, monitoring serves
duration of meal, an important role in
social situation, the maintenance of
overall mood, internal standards
activities of behavior.
accompanying
 consumption).

 Weigh patient  It is important to

twice a week patient and their
under the same progress to have an
conditions. actual reward that
the scale shows.
Monitoring twice a
week keeps the
patient on the
program by not
allowing him to eat
out of control.

 Guide the patient  Even modest

regarding weight loss
changes that will contributes to
make a major diabetes and
impact on health. hypertension
control.
 Provide the  The goal is to
patient and obtain a permanent
family with change in weight
information management, the
regarding the decision regarding
treatment plan treatment plans
options. should be left up to
the patient and
family.
 Teach stress  The patient needs to
reduction substitute healthy
methods as for unhealthy
alternatives to behaviors.
eating.
 Problem and Cues Nursing Diagnosis / Planning/Objective Nursing Interventions Rationale Evaluation
(Assessment) Scientific Rationale

Objective: Risk for impaired tissue Short term goal: Independent After the intervention, the goal was partially
integrity related to fluid After 8hrs of nursing met.
 Integumentary: retention and edema. intervention:  Assess the  Assessment of the
Pallor  Patient will be overall condition condition of the  Patient was able to reports any altered
able to reports of the skin. skin provides sensation or pain at site of tissue
 The Lower any altered baseline data for impairment.
extremities where sensation or pain possible
remarkable for 3+ at site of tissue interventions for  Patient was able to demonstrates
pitting edema. impairment. the nursing understanding of plan to heal tissue
diagnosis Risk for and prevent injury.
 Patient will be Impaired Skin
able to Integrity.  Patient was able to describes measures
demonstrates to protect and heal the tissue,
understanding of  Encourage the  Turning every 2 including wound care.
plan to heal implementation hours is the key to
tissue and of a turning prevent breakdown.  Patient’s wound was decreased in size
prevent injury. schedule, Head of bed should and has increased granulation tissue.
restricting time be kept at 30
Long term goal: in one position to degrees or less to
After 3days of nursing 2 hours or less, if avoid sliding down
intervention: the patient is on bed.
restricted to bed.
 Patient will be
able to describe  Use pillows or  These measures
measures to foam wedges to reduce shearing
protect and heal keep bony forces on the skin.
the tissue, prominences
 including wound from direct
care. contact with
each other. Keep
 Patient’s wound pillows under the
will decreases in heels to raise off
size and has bed.
increased
granulation  Encourage  Ambulation reduces
tissue. ambulation if the pressure on the skin
patient is able. from immobility
thus lessening the
factors that may
result in impaired
skin integrity.

 Assess for  Skin tightened

edema. tautly over
edematous tissue is
at risk for
impairment.

 Assess the  A typical cause of

amount of shear shear is elevating
(pressure exerted the head of the
laterally) and patient’s bed: the
friction (rubbing) body’s weight is
on the patient’s displaced
skin. downward onto the
patient’s sacrum.
Typical causes of
friction include the
patient rubbing
heels or elbows
against bed linen,
and moving the
patient up in bed
without the use of a
lift sheet.
 For patients with  This is to identify
limited mobility, patients at risk for
use a risk immobility-related
assessment tool skin breakdown.
to systematically
assess
immobility-
related risk
factors.
 Massage only  This is to increase
around affected tissue perfusion.
area. Massaging the
actual reddened
area may damage
the skin further.

 Assess for  Moisture may

environmental contribute to skin
moisture (e.g., maceration.
wound drainage,
high humidity).

 Educate patients  Educating patients

and caregivers and caregivers
about proper methods to
skin care. maintain skin
integrity enhances
their sense of self-
efficacy and
prevents skin
breakdown.
 Problem and Cues Nursing Diagnosis / Planning/Objective Nursing Interventions Rationale Evaluation
(Assessment) Scientific Rationale

Objective: Impaired physical mobility Short term goal: Independent: After the intervention, the goal was partially
related to intolerance to After 8hrs of nursing met.
 The patient had activity/decreased strength and intervention: Check for functional  Patient was able to perform physical
noted a 30 pound endurance as evidenced by level of mobility. activity independently or within limits
weight gain over weight gain  Patient will be  Level 1: Walk, of disease.
the past month able to perform regular pace, on  Understanding the  Patient was able to demonstrates
 Anthropometric physical activity level particular level, measures to increase mobility
Measures: independently or indefinitely; one guides the design of  Patient was able to demonstrates the
Body Weight: within limits of flight or more best possible use of adaptive devices to increase
101kg disease. but more short of management plan. mobility
 Patient will be breath than  Patient was able to reduce
able to normally complications of immobility, as
demonstrates evidenced by intact skin.
measures to Level 2: Walk
increase mobility one city block or
 Patient will be 500 ft on level;
able to climb one flight
demonstrates the slowly without
use of adaptive stopping
devices to
increase mobility Level 3: Walk no
more than 50 ft
Long term goal: on level without
After 3days of nursing stopping; unable
intervention: to climb one
 Patient will be
able to reduce flight of stairs
the without stopping
complications of
immobility, as Level 4: Dyspnea
evidenced by and fatigue at
intact skin. rest.

 Evaluate
patient’s ability  Restricted
to perform movement
Activities of influences the
Daily Living capacity to perform
efficiently and most activities of
safely on a daily daily living. Safety
basis. with ambulation is
a significant matter.
0 – Completely Determines
independent strengths or
insufficiency and
1 – Requires use may give
of equipment or information
device regarding recovery.

2 – Requires
help from
another person
for assistance,
supervision, or
teaching

3 – Requires
help from
another person
and equipment
or device

4 – Is dependent,
 does not
participate in
activity.

 Assess the  This assessment

strength to provides data on
perform ROM to extent of any
all joints. physical problems
and guides therapy.
Testing by a
physical therapist
may be needed.

 Monitor  Good nutrition also

nutritional needs gives required
as they relate to energy for
immobility. participating in an
exercise or
rehabilitative
activities.

 Evaluate the  Correct utilization

need for assistive of wheelchairs,
devices. Show canes, transfer bars,
the use of and other assistance
mobility devices, can enhance
such as the activity and lessen
following: the danger of falls.
trapeze, crutches, The goals of using
or walkers. mobility devices
are to promote
safety, enhance
mobility, avoid
falls, and conserve
energy.
  Acceptance of
temporary or more
 Assess the permanent
emotional limitations can vary
response to the broadly between
disability or individuals. Each
limitation. person has his or
her personal
interpretation of
acceptable quality
of life.

 These measures
promote a safe,
 Present a safe secure environment
environment: and may reduce risk
bed rails up, bed for falls.
in a down
position,
important items  This is to prevent
close by. skin breakdown,
 Establish and the
measures to compression
prevent skin devices promote
breakdown and increased venous
thrombophlebitis return to prevent
from prolonged venous stasis and
immobility: possible
 Clean, dry, and thrombophlebitis in
moisturize skin the legs.
as necessary.
 Use anti embolic
stockings or
sequential
compression
devices if
appropriate.
 Use pressure-
relieving devices
as indicated (gel
mattress).
 Exercise enhances
 Execute passive increased venous
or active return, prevents
assistive ROM stiffness, and
exercises to all maintains muscle
extremities. strength and
stamina. It also
avoids contracture
deformation, which
can build up
quickly and could
hinder prosthesis
usage.

 Healthcare
 Let the patient providers and
accomplish tasks significant others
at his or her own are often in a hurry
pace. Do not and do more for
hurry the patient. patients than
Encourage needed. Thereby
independent slowing the
activity as able patient’s recovery
and safe. and reducing his or
her confidence.

 Position changes
 Turn and optimize circulation
position the to all tissues and
patient every 2 relieve pressure.
hours or as
needed.
 Providing small,
 Give explanation attainable goals
about helps increase self-
progressive confidence and
activity to reduces frustration.
patient.
 Problem and Cues Nursing Diagnosis / Planning/Objective Nursing Interventions Rationale Evaluation
(Assessment) Scientific Rationale
Subjective:
 The patient knew
Anxiety related to Short term Independent: After the intervention, the goal was met.
he had arterial powerlessness as evidenced by After 8hrs of
hypertension, presence of comorbidity. nursing  Assess physical  Anxiety also plays a  The patient will be able to relax and
intervention: reactions to anxiety. role in somatoform reduce the anxiety.
ischemic heart
disorders, which are
disease, and renal The patient will be characterized by
able to relax and physical symptoms  The patient was able to know some of
failure (undergoing reduce the anxiety. such as pain, nausea the techniques on how to lessen
renal replacement and weakness. anxiety.
The patient will be
therapy). able to know some of  Validate  Anxiety is a highly  The patient’s anxiety was reduced.
the techniques on observations by individualized,
how to lessen asking patient, “Are normal physical and
Objective: anxiety. you feeling anxious psychological
 He also had now?” response to internal
or external life
myocardial
events.
infarction in
Long term  Establishing a  An ongoing
January 2015. After 3days of working relationship
nursing relationship with establishes a basis
 Restlesness intervention: the patient through comfort in
 Weakness continuity of care. communicating
 Pallor The patient’s anxiety anxious feeling.
will be reduce..
 Provide accurate  Helps patient to
information about identify what is
the situation. reality based.

 Recognize  Acknowledgment of
awareness of the the patient’s feelings
patient’s anxiety. validates the feelings
and communicates
acceptance of those
feelings.

 Use presence, touch  Being supportive and

(with permission), approachable
verbalization, and promotes
demeanor to remind communication.
patients that they
are not alone and to
encourage
expression or
clarification of
needs, concerns,
unknowns, and
questions.

 Interact with patient  The patient’s feeling

in a peaceful of stability increases
manner. in a calm and non-
threatening
environment.

 Converse using a  When experiencing

simple language moderate to severe
and brief anxiety, patients may
statements. be unable to
understand anything
more than simple,
 clear, and brief
instruction.

 Reinforce patient’s  Talking or otherwise

personal reaction to expressing feelings
or expression of sometimes reduces
pain, discomfort, or anxiety.
threats to well-
being (e.g., talking,
crying, walking,
other physical or
nonverbal
expressions).

 Help patient  Obtaining insight

determine allows the patient to
precipitants of reevaluate the threat
anxiety that may or identify new ways
indicate to deal with it.
interventions.