Assessment

Nursing Diagnosis

Planning

Nursing Intervention

Rationale

Evaluation

SUBJECTIVE: Deficient After 8 hours VIII. kaya NURSING knowledge CARE PLANof nursing Bakit 2012 madalas regarding interventions, sumsasakit ulo condition, the patient ko at nahihilo? therapeutic will verbalize as verbalized by regimen and understandin the patient. potential g of the complications disease OBJECTIVE: process and treatment Request for regimen. information. Agitated behavior irritable V/S taken as follows: T: 36.3 P: 82 R: 21 BP: 140/90

Define and state the limits of desired BP. Explain hypertension and its effect on the heart, blood vessels, kidney, and brain.

Assist the patient in identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol. Reinforce the importance of adhering to treatment regimen and keeping follow up appointments. Suggest frequent position changes, leg exercises when lying down.

After 8 hours of Provides basis for Date: December 12, understanding elevations of nursing interventions, the BP, and clarifies patient was able misconceptions and also understanding that high BP to verbalize understanding of can exist without symptom the disease or even when feeling well. process and These risk factors have been shown to contribute to treatment regimen. hypertension.

Lack of cooperation is common reason for failure of antihypertensive therapy.

Decreases peripheral venous pooling that may be potentiated by vasodilators and prolonged sitting or standing. Two years on moderate low salt diet may be sufficient to control mild hypertension. Caffeine is a cardiac stimulant and may adversely affect cardiac function. Alternating rest and activity increases tolerance to activity progression.

Encourage patient to decrease intake of sodium rich foods

Encourage patient to decrease or eliminate caffeine like in tea, coffee, cola and chocolates. Stress importance of accomplishing daily rest periods.

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Date: December 12,

ASSESSMENT Subjective: madalas ako mahilo, as verbalized by the patient.

DIAGNOSIS Decreased Cardiac Output r/t decreased venous return

PLANNING After 6 hrs of nursing interventions, the client will have no elevation in blood pressure above normal limits and will maintain blood pressure within

INTERVENTION monitor BP every 1-2 hours, or every 5 minutes during actve titration of vasoactive drugs.

RATIONALE changes in BP may indicates changes in patient status requiring prompt attention.

EVALUATION Goal partially met. After 6 hrs of nursing interventions, the client still has elevation of blood pressure above normal limits.

Objective: >lethargic

VIII. NURSING CARE PLAN 2012

>prolonged capillary refill-3 seconds >VS taken as follows: T: 36.3 P: 82 R: 21 BP: 140/90 acceptable limits. suggest frequent position changes.

Date: December 12,

it may decreases peripheral venous pooling that may be potentiated by vasodilators and prolonged sitting or standing. encourage patient to decrease intake of caffeine, cola and chocolates. caffeine is a cardiac stimulant and may adversely affect cardiac function.

observe skin color, temperature, capillary refill time and diaphoresis.

peripheral vasoconstriction may result in pale, cool, clammy skin, with prolonged capillary refill time due to cardiac dysfunction and decreased cardiac output.

administer medicines

to promote wellness.

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as prescribed by the physician . instruct client & family on fluid and diet requirements and restrictions of sodium.

Date: December 12,

restrictions can assist with decrease in fluid retention and hypertension, thereby improving cardiac output.

instruct client and family on medications, side effects, contraindications and signs to report. Assessment Diagnosis Planning Implementation

promotes knowledge and compliance with drug regimen.

Rationale

Evaluation

VIII. NURSING CARE PLAN 2012

Subjective: nahihilo ako as verbalized by the patient Objective: bed has no side rails V/S taken as follows: T: 36.3 P: 82 R: 21 BP: 140/90 Risk for injury related to absence of side rails secondary to dizziness After 6 hrs of nursing interventions, the client will not acquire injury within the confinement. Monitor vital signs every 2 hours. Assess for muscle strength.

Date: December 12,

To obtain baseline for comparison. To be able to know if the patient can move according to want he needs. To have close monitoring and prevent from getting injury.

Goal met. Patient didnt acquire injury within the confinement.

Instructed the watcher to closely watch the patient to prevent from falling or slipping. Instructed patient to increase fluid intake and adequate diet. Stress importance of accomplishing daily rest periods.

To replace fluid loss and regain energy.

Alternating rest and activity increases tolerance to activity progression.