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ASSESSMENT EXPLANATION OF OBJECTIVES NURSING RATIONALE EVALUA

THE PROBLEM INTERVENTIONS TION


Subjective: Normally, there is STO: within 2 Diagnostic Fully met:
Magpapacheck- significant increase in hours of 1.) Assessed vital signs (BP, 1.) To determine the Patients
up lang sana ako, blood pressure among nursing HR) effectiveness of BP:
kaso nahilo at pregnant women interventions, intervention. 130/90,
tumaas BP ko during their course of client will have 2.) Assessed peripheral 2.) To identify possible absence of
pregnancy period. BP of less than extremities presence edema, dizziness
It is a response of the or equal to varicosities or swelling. and
Objective: body to the increase in 130/90mmHg, tingling
Vital signs: blood volume. absence of Therapeutic sensation
BP: However, it becomes dizziness and 1.) Administered 1.) To reduce blood fluid on both
150/100mmHg fatal if not monitored tingling magnesium sulfate via volume by means of hands.
CR: 102 bpm regularly. sensation on solu-set increasing urine output.
SpO2: 94% both hands 2.) To meet oxygen demand
RR: 20 cpm Due to the increased 2.) Given low flow oxygen by the increased heart
blood pressure, there (1-2 lpm) via nasal rate.
cannula 3.) To allow full lung
No signs of edema is a decreased cardiac
3.) Positioned to semi- expansion and allows
on extremities due to increase in
fowlers. more air to enter the
Not distended heart rate resulting to
lungs
jugular vein inadequate blood
No signs of pumped by the heart.
4.) Provided warm blanket 4.) To provide warmth.
paleness
Capillary refill and Decreased cardiac
skin turgor less output is defined as Educative
1.) Taught deep breathing 1.) To reduce stimuli and
than 1 second inadequate blood
exercises produce calming effect
With pulse grade pumped by the heart
reducing BP
of +2 to meet the metabolic
2.) Emphasized importance 2.) Lessens physical stress
With tingling demands of the body.
of adequate rest and and tension that affect
sensation on both
limit strenuous activities increase in blood
hands pressure
Not in respiratory References
distress. Doenges, M., 3.) To increase venous
3.) Instructed to ambulate
Moorhouse, M., & return.
feet regularly
Nursing Murr, A. (2009).
Diagnosis Nurse's pocket guide. 4.) Instructed to report
Decreased cardiac Philadelphia: Davis dizziness and difficulty 4.) To provide proper
output related to Company. in breathing. medical and nursing
increased heart management as needed.
rate.

ASSESSMENT EXPLANATION OF OBJECTIVE NURSING RATIONALE EVALUAT


THE PROBLEM S INTERVENTIONS ION
Subjective: It is normal for a STO: after 30 Diagnostic Fully met:
Kinakabahan kasi person to get anxious mins of 1.) Assessed stressors 1.) To determine Patient was
ako lagi kapag during clinical nursing contributing to anxiety appropriate able to
nagpapacheck-up consultation or check- intervention interventions and relax as
up. In the case of our patient will be evaluate degree of manifested
patient, she gets in a relaxed Therapeutic anxiety by calm
Objective: anxious every time she state as 1.) Use presence, touch 1.) Being supportive and face, able
Observed to goes for a check-up, manifested by (with permission), approachable promotes to interact
holding and reason was the result calm face and verbalization, and communication clearly,
rubbing both may not desirable or non-shaky demeanor to remind understand
hands. not as she expected as hands with patients that they are s the
Noted to be texting claimed by the stable vital not alone and to situation ,
her son to come see patient. signs 2.) Diverted patient 2.) Talking or otherwise non-shaky
her as soon as BP: =< attention. expressing feelings hands, and
possible 130/90mmHg sometimes reduces vital signs
Shaky hands And CR: < 100 anxiety. of BP:
Vital signs: References: bpm Educative 130/90mm
BP: 150/100mmHg 1.) Encourage expression or 1.) Talking about anxiety- Hg, CR:
CR: 102 bpm Doenges, M., clarification of needs, producing situations and <100 bpm
SpO2: 94% Moorhouse, M., & concerns, unknowns, anxious feeling can help the
RR: 20 cpm Murr, A. (2009). and questions about patient perceive the situation
Nurse's pocket guide. hospitalization. realistically and recognize
Philadelphia: Davis factors leading
Company.
2.) Taught deep breathing 2.) Promotes relaxation
Nursing exercises and provided
Diagnosis calm environment
Anxiety related to
3.) Familiarize patient with 3.) Awareness of the
hospitalization
the environment and environment promotes
new experiences or comfort and may
people as needed. decrease anxiety
experienced by the
patient. Anxiety may
intensify to a panic level
if patient feels threatened
and unable to control
environmental stimuli.