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    Cues Nursing Diagnosis Analysis Goal Nursing Intervention Rationale Evaluation

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    ccchelle14
    The client presented with high blood pressure and cold, clammy skin. Nursing diagnoses included decreased tissue perfusion related to peripheral vasoconstriction as evidenced by the client's verbal complaints and objective findings of high blood pressure and delayed capillary refill. Goals were to maintain blood pressure and capillary refill within normal ranges through nursing interventions such as rest, monitoring of vital signs, administration of antihypertensive medications, and encouraging compliance with dietary and fluid restrictions.

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    Cues Nursing Diagnosis Analysis Goal Nursing Intervention Rationale Evaluation

    Uploaded by

    ccchelle14
    945 views5 pages
    The client presented with high blood pressure and cold, clammy skin. Nursing diagnoses included decreased tissue perfusion related to peripheral vasoconstriction as evidenced by the client's verbal complaints and objective findings of high blood pressure and delayed capillary refill. Goals were to maintain blood pressure and capillary refill within normal ranges through nursing interventions such as rest, monitoring of vital signs, administration of antihypertensive medications, and encouraging compliance with dietary and fluid restrictions.

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    CUES Subjective:

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    The client presented with high blood pressure and cold, clammy skin. Nursing diagnoses included decreased tissue perfusion related to peripheral vasoconstriction as evidenced by the client's verbal complaints and objective findings of high blood pressure and delayed capillary refill. Goals were to maintain blood pressure and capillary refill within normal ranges through nursing interventions such as rest, monitoring of vital signs, administration of antihypertensive medications, and encouraging compliance with dietary and fluid restrictions.

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    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    945 views5 pages

    Cues Nursing Diagnosis Analysis Goal Nursing Intervention Rationale Evaluation

    Uploaded by

    ccchelle14
    The client presented with high blood pressure and cold, clammy skin. Nursing diagnoses included decreased tissue perfusion related to peripheral vasoconstriction as evidenced by the client's verbal complaints and objective findings of high blood pressure and delayed capillary refill. Goals were to maintain blood pressure and capillary refill within normal ranges through nursing interventions such as rest, monitoring of vital signs, administration of antihypertensive medications, and encouraging compliance with dietary and fluid restrictions.

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    CUES NURSING ANALYSIS GOAL NURSING RATIONALE EVALUATION

    DIAGNOSIS INTERVENTION

    Subjective: Hyperthermia Fever is a After 4 hrs. Of After 4 hrs. Of


    frequent medical nursing nursing
    sign that interventions, the Promote surface To decrease interventions, the
    describes an patient will cooling by means temperature by patient was able
    The client of tepid sponge means through
    increase in maintain core maintain core
    verbalized: bath. evaporation and
    internal body temperature temperature
    temperature to within normal conduction. within normal
    “Mainit ang
    pakiramdam ko” levels above range. range.
    normal. Fever is
    most accurately
    characterized as
    “Panagtlong araw a temporary To minimize
    na ako nilalagnat elevation in the Wrap extremities shivering.
    eh” body's with cotton
    thermoregulatory blankets.
    set-point, usually
    by about 1–2 °C
    (1.8-3.6 °F).

    Fever is caused Provide To offset


    Objective: by an elevation supplemental increased oxygen
    in the oxygen. demands and
    thermoregulatory consumption.
    set-point, causing
    Flushed skin
    typical body
    warm to touch. temperature
    (generally and
    Restless problematically
    To facilitate fast
    considered to be Administer
    Diaphoretic recovery.
    37 °C or 98.6 °F) antipyretics
    to rise, and orally or rectally
    Chills
    effector as prescribed by
    mechanisms are the physician.
    enacted as a
    result. A feverish
    individual has a
    Measurement: Monitor Vital
    general feeling of
    signs
    BP : 110/70 cold despite an To monitor the
    increased body increase and
    T : 38.5 oC temperature, and decreases in
    increases in temperature.
    heart rate,
    muscle tone and
    shivering, all of
    which are caused
    by the body's
    attempts to
    counteract the
    newly perceived
    hypothermia and
    reach the new
    thermoregulatory
    set-point.
    CUES NURSING ANALYSIS GOAL NURSING RATIONALE EVALUATION
    DIAGNOSIS INTERVENTIO
    N

    Subjective: Decreased Constriction of At the end of Measure and Provides At the end of
    tissue perfusion the peripheral the shift, the recorded blood objective data the shift, the
    related to blood vessels client will pressure. for monitoring. client was able
    peripheral will alter the maintain a to maintain a
    The client
    vasoconstriction flow of blood to blood pressure blood pressure
    verbalized:
    as manifested perfuse the within the within the
    “matagal ng by high blood different cells of normal range normal range
    mataas ang pressure. the body. Observed skin Presence of
    presyon ng color, moisture, pallor: cool,
    dugo ko.” temperature, moist skin; and
    and capillary delays capillary
    refill time. refill time may
    be due to
    “wala naman
    peripheral
    ako iniinum na
    vasoconstriction
    mga gamot
    .
    para bumababa
    yung bp ko”

    Reduces
    Provided calm, physical stress
    Objective:
    restful and tension that
    surroundings, affect blood
    minimize pressure and
    Cold clammy environmental the course of
    skin activity/noise. hypertension.
    Limit the
    number of
    Decreased visitors and
    capillary refill length of stay.
    Measurement:

    BP : 160/100 Maintain activity Decreases


    mmHg restrictions; discomfort and
    such as bed may reduce
    rest/chair rest; sympathetic
    schedule stimulation
    periods of
    uninterrupted
    rest; assisted
    client with self-
    care activities
    as needed.

    Administered
    antihypertensiv
    e medications
    as prescribed Antihypertensiv
    e medications
    play a key role
    in treatment of
    hypertension
    associated with
    chronic renal
    failure.

    Encouraged Adherence to
    compliance with diet and fluid
    dietary and fluid restrictions and
    restriction dialysis
    therapy schedule
    prevents excess
    fluid and
    sodium
    accumulation

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