ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective data:
Objective data:
GCS: 6
Difficulty
breathing (Use of
accessory
muscles)
Tachycardia
Tachypnea
Vital Signs:
BP- 158/100 mmhg
Temp- 37.9 C
RR- 42 cpm
PR- 140 bpm
SPO2: 88 %
Ineffective cerebral
tissue perfusion related
to inflammatory
processes
Within 8 hours of
nursing interventions,
the client will be able
to demonstrate stable
vital signs and display
no further
deterioration/
recurrence of deficits
Independent
Monitor Vital Signs
After 3 hours of nursing
intervention, the client
verbalized pain is
relieved or controlled
with a pain scale of
3/10.
Goal met
