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Rationale Evaluation

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STG: 4.

encourage affect cardiac


ASSESSMENT
After 6 hrs of patient function.
nursing to decrease
Subjective:
interventions, the intake of 5. peripheral
“madalas ako
client will have no caffeine, cola and vasoconstriction
mahilo”, as
elevation in blood chocolates. may result in
verbalized by the
pressure above pale,
patient.
normal limits and 5. observe skin cool, clammy
will maintain color, skin,
Objective:
blood temperature, with prolonged
>lethargic
pressure within capillary refill time capillary refill time
>decreased
acceptable limits. and diaphoresis.
cardiac
EVALUATION
output LTG: RATIONALE
>decreased STG:
stroke After 5 days of 1. changes in BP After 6 hrs of
volume nursing may indicates nursing
>increased interventions, the changes in interventions, the
peripheral client will maintain patient client had no
vascular adequate cardiac status requiring elevation in blood
resistance output and prompt attention. pressure above
>VS taken as cardiac 2. decrease in normal limits and
follows: index. cardiac output will maintain
may blood
T: 37.2
INTERVENTIO result in changes pressure within
N in acceptable limits.
PR: 83
RR: 18 cardiac perfusion Goal was met.
1.monitor BP
BP: 180/100 causing
every LTG:
dysrhythmias.
1-2 hours, or
DIAGNOSIS 3. it may
every After 5 days of
decreases
5 minutes during nursing
Decreased peripheral venous
actve titration of interventions, the
Cardiac pooling that may
vasoactive drugs. client maintained
Output r/t be
2. monitor ECG an
malignant potentiated by
for adequate cardiac
hypertension as vasodilators and
dysrrhythmias, output and
manifested by prolonged sitting
conduction cardiac
decreased stroke or
defects index.
volume. standing.
and for heart rate. Goal was met.
4. caffeine is a
PLANNING 3. suggest cardiac stimulant
frequent and may
position changes. adversely

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