NURSING CARE PLAN

ASSESSMENT DATA (Subjective&objective)

NURSINGDIAGNOSES

GOALS & OBJECTIVES

NURSING INTERVENTIONS INDEPENDENT: > Assess vital signs, noting tachycardia, hypertension, and increased respiration, even if client denies pain. R- Changes in these vital signs often indicate acute pain and discomfort. Note: Some clients may have a slightly lowered BP, which returns to normal range after pain relief is achieved. >provide comfort measures. R- to provide non-pharmacologic pain management DEPENDENT >Encourage use of relaxation techniques such as deepbreathing exercises, guided imagery, visualization, or music. R- Relieves muscle and emotional tension; enhances sense of control and may improve coping abilities. COLLABORATIVE: >Give PRN meds for pain such as analgesics as prescribed R-to relieve pain.

EVALUATION

Subjective cues: I felt pain in my finger tips as verbalized.

Acute pain related to tissue ischemia secondary to vasospasm

After 8 hours of nursing interventions, the patient will be able to experience gradual reduction/relief of pain. from 4/10 to 0/10.

Goal was partially met as evidenced by After 8 hours of nursing interventions; the patient was able to experience gradual reduction/relief of pain. from 4/10 to 2/10.

Objective cues: Bluish discoloration of the palms Pain 4/10 Pallor Facial grimace
Capillary refill of 4-5 seconds

NURSING CARE PLAN

ASSESSMENT DATA (Subjective&objective)

NURSINGDIAGNOSES

GOALS & OBJECTIVES

NURSING INTERVENTIONS

EVALUATION

Subjective cues: nagiiba kulay ng kamay ko it turns to blue from white as verbalized.

Ineffective peripheral tissue perfusion related to lack of supplies to extremities secondary to vasospasm

DEPENDENT: >Asses the patient for the blood The goals was partially met as Within 8 hours of rendering Nursing care the patient will be circulation, color and sensation at evidenced by Within 8 hours the extremities of rendering Nursing care the able to Rfor further investigation and patient was be able to Increased arterial blood
supply to extremities. Palms turn to normal color. treatment. >apply warm compress at the affected area. R-to promote good blood circulation > monitor the blood circulation to the extremities every 2hrs. R-to observe any further complication INDEPENDENT: >Encourage patient to perform extremities exercises while sitting. R- Muscular exercises promote blood flow and the development of collateral circulation. COLLABORATIVE: >Losartan 50 mg, OD R- to vasodilate the blood vessel and to increase blood supply to the exremeties Increased arterial blood supply to extremities. Palms turns to pinksish.

Objective cues: Fingertips are cyanotic Pallor Coldness of extremities

Capillary refill of 4-5 seconds numbness

NURSING CARE Plan

ASSESSMENT DATA (Subjective&objective)

NURSINGDIAGNOSES

GOALS & OBJECTIVES

NURSING INTERVENTIONS

EVALUATION

Subjective cues: Natatakot ako na baka ma ampute ang kamay ko later on As verbalized.

Anxiety related to disease process

>At the end of the shift patient will be able to reduced anxiety level

DEPENDENT: >assess patient anxiety level by observing the clients behaviors e.g. Crying, facial expression and anxious R-to further investigate >provide moral and emotional support to patient R- to provide patient psychological comfort >reinforce doctors explanations to patient by using non medical term R-to increase the understanding of the patient about the disease. INDEPENDENT: >encourage divertional therapy R- to deviate clients mind away from the disease and to avoid the patient get mentally stress.

Te goal was met. At the end of the shift patient was able to reduced anxiety level As evidenced by client is more clear about the disease

Objective cues: Bluish discoloration of both palms Pale Coldness of upper extremities Capillary refill of 4-5 seconds