Nursing Planning Nursing Intervention Rationale Nursing

Assessment Evaluatio
n
Subjective: STO: Independent: Independent:
N/A After 8 hours of A. Assessed A. Note
nursing contributing B. Hehe
intervention the factors
Objective: patient will: B.
 Restless A. Verbalizes
 Diaphore less Dependent:
tic concern A. To support
 Pale, cool related to Dependent: oxygenatio
clammy breathing A. Administered n and
skin and chest oxygen support perfusion
 +2 pitting pain as per doctor’s to ensure
edema B. Maintain order. gas
Vital Signs as Normal B. Administered exchange
follows: Vital Signs prescribed
T: 36.9C C. Be calm medications to
BP: 110/90mmHg and regain treat
RR: 29 cpm normal skin underlying
PR: 102 bpm color. problem.
SpO2: 90%
LTO: - Antihypertensi
After 72 hours of ve drugs
continuous nursing - Peripheral
intervention the vasodilators
Nursing Diagnosis: patient will:
Risk for Ineffective A. Demonstrat
Tissue Perfusion e behaviors
related to and
insufficient blood lifestyle
flow to the organs changes to
and tissues as improve
evidenced by pale circulation
and cool clammy (proper
skin. diet,
cessation in
smoking
and alcohol
drinking)
B. Regain and
maintain
optimal
physical
well-being