KRISTEL ANN EVANGELISTA BSN 111-A-11 GROUP 39

Cues/Needs Nursing Rationale Goals and Interventions Rationale Evaluation

Diagnosis Objectives
Subjective: Independent: After 8 hrs of
Risk for Indwelling After 8 hrs of >monitor vital -change in vital nursing
Objective: infection r/t catheter nursing signs signs indicate interventions
>has indwelling indwelling increased the interventions Particularly change in health patient was
catheter since catheter and risk for being patient will be temperature status free from
sept.4,2009 inadequate invaded by free from infection as
secondary pathogenic infection as -a first –line evidenced by
>hemoglobin 98g/L defenses. organisms evidenced by >Stress proper defense against afebrile
(normal: 135-180) afebrile hand hygiene healthcare- condition.
condition, associated The goal was
increased infections partially met.
hemoglobin level
within normal -to reduce
range. >clean insertion potential
site with catheter-related
appropriate blood stream
solution infections.

Dependent: -to prevent

>regularly replace infection caused
the catheter as by prolongrd use
ordered by the of catheter.
physician.

Collaborative: -To
>advise relatives prevent/reduce
 and other visitor of cross-
the patient to wash contamination.
their hand and wear
mask inside the
ward.
Subjective: Acute pain r/t hypertension After 8hrs of Idependent: After 8hrs of
-client reports pain increased causes pain nursing nursing
cerebrovascular and interventions >monitor vital -changes in interventions
pressure. discomfort patient will be signs particularly vitalsigns patient was
because of able to report that the BP indicates change able to report
Objective: increased pain is relieved/ in health status that pain is
-BP: 140/80 Cerebrovascu controlled and BP relieved/
lar pressure will decrease controlled and
-restlessness within normal >provide comfort -to promote BP had
range. measures e.g. nonpharmacologi decreased to
-reduced interaction touch, cal pain 120/80.
with people Long term: repositioning, use management The goal was
Patient will be of heat and cold fully met.
able to maintain packs, nurse,s
BP within normal presence
range.
>encourage -to prevent
adequate rest fatigue
periods

>instruct / -to distract

encourage ase of attention and
relaxation reduce tension
techniques such as
focused breathing
Dependent:

>administer
amlodipine 10mg t -to treat
TAB OD hypertension
As prescribed by
the physician

>administer
analgesics like
aspirin as -to control pain
prescribed by the
physician

Collaborative:

>instruct the
dietician to provide
the patient with diet -to prevent
low in sodium and condition from
fat. worsening.