Assessment Diagnosis Planning Intervention Evaluation

60 years of Age Decreased Cardiac Short Term: Independent: Goals are met.
Pale, Weak & Output as evidence Within 8 hours: Patient’s ankle is
Frightened by changes in blood 1. Palpate the area of symmetrical and
Ankle Edema pressure and edema • Record family swelling/edema for any equal in size.
risk for history of heart signs of Pain.
Vital Signs: Cardiovascular Patient’s blood
BP: 98/52 mmHG Disease and Heart
disease from
patient and
 To determine the pressure changed
Temp: 37.5 failure. family outputs. area’s level of from 98/52 to
Apical P: 64 abnormality. 120/80.
Rp: 28 cycles/min Long Term:
Within 2 weeks: 2. Perform a functional Patient displays
*DIAGNOSED with test for ROM of the and verbalizes an
CVD* • Patient’s blood ankle. alert and healthy
pressure will  To determine the appearance and
behavior.
display a change patient’s level of
from 98/52 to mobility.
120/80.
3. Educate Patient and
• Absence of Relatives for Dietary
Edema in the management.
ankle, displaying
a symmetrical  Dietary Mgt can help
and equally the patient reduce the
shaped ankle. odds leading to CVD.

• Patient will Collaborative:

display a alert, Dietary management:
healthy and
assertive 1. Restrict Sodium from
behavior and the range of 500 to
physical 100mgs.
appearance.
 Sodium should be
restricted to control
Edema.

2. Restrict Fluid intake.

 Fluid intake should be
monitored because
edematous patient's
inability to excrete free
water may aggravate
the ankle.
3. Small Frequent
Feedings.
 To decrease
circulatory load.