XIII.

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Ineffective At the end of my 8 hours INDEPENDENT: At the end of my 8
“Wala koy alamag tissue care, the patient will be 1. Asses vital signs, 1. To identify the hours care, the patient
nga gi admit diay ko. perfusion able to: capillary refill extent of perfusion will be able to:
Akong nabatian ato related to test, and ECG. to tissues.
kalipong ug diminished LONG TERM GOAL: 2. Assess skin color 2. For changes that LONG TERM GOAL:
namugnaw na ko.” As venous 1. Demonstrate and temperature might indicate 1. PARTIALLY
verbalized by the return as increased perfusion in all extremities. circulation problem. MET -
patient. evidenced by as individually 3. Assess for rapid 3. Restlessness Demonstrate
delayed appropriate (e.g., changes or and anxiety are increased
OBJECTIVE: capillary skin warm and dry, continued shifts early signs of perfusion as
Physical refill, cold peripheral pulses in mental status. cerebral hypoxia individually
Assessment: clammy skin, present and strong, while confusion and appropriate
 Skin is dry and pale color absence of edema, loss of (e.g., skin
shows red and clubbing free of pain or consciousness warm and dry,
spots all over of fingers. discomfort). occur in the later peripheral
the body. stages. pulses present
 Skin SHORT TERM GOALS: 4. Record BP 4. Stable BP is needed and strong,
temperature is readings for to keep sufficient absence of
cold in both 1. Maintain vital signs orthostatic tissue perfusion. edema, free of
two feet and within normal range changes (drop of pain or
two hands. such as 20 mm Hg discomfort).
 Visible temperature 36.5˚C systolic BP or 10
clubbing of – 37.5˚C, O2 Sat mm Hg diastolic SHORT TERM
nails. 95%- 98%. BP with position GOALS:
 Greater than 2. Demonstrate changes).
180 ˚ angle hydrated skin and 5. Monitor 5. Hemoglobin is a red 1. PARTIALLY
 Bluish tint mouth. hemoglobin blood cell MET - Maintain
(cyanosis) 3. Demonstrate levels. component that vital signs
 Excessive appropriate lifestyle carries oxygen within normal
thickness modifications to through the body. If range such as
support adequate hemoglobin is temperature
  Delayed return tissue perfusion. decreased, less 36.5˚C –
of usual color. oxygen will be 37.5˚C O2 Sat
 Dry mucous perfused through 95%- 98%.
membrane the body and 2. PARTIALLY
tissues. MET-
Vital signs: 6. Determine pulse 6. To evaluate Demonstrate
 T: 35˚C equality, as well distribution and hydrated skin
 O2 Sat: 93 % as intensity (e.g., quality of blood flow and mouth.
 RR: 15 bpm bounding, and success or 3. PARTIALLY
 PR: 63 bpm normal, failure of therapy. MET -
diminished, or Demonstrate
 BP: 120/80
absent), and appropriate
mmHg
compare with lifestyle
unaffected modifications to
Lab Results:
extremity. support
HgB – LOW
7. Note client’s 7. Dehydration adequate
HCT – LOW
nutritional and reduces blood tissue
RBC – LOW
fluid status. volume and perfusion.
compromises
peripheral
circulation.
8. Position the 8. To increase
patient to semi- oxygenation of
fowler’s position. lungs.
9. Advice the client 9. To conserve oxygen
to avoid tissues and prevent
strenuous fatigue.
activities.
DEPENDENT:
1. Refer to the 1. For further
doctor. intervention.
2. Administer fluids, 2. To promote optimal
electrolytes, blood flow, organ
nutrients, and perfusion, and
oxygen, as function.
indicated.
3. Do a cross match 3. To replace red
and RH typing for blood cells.
blood transfusion
as needed.