I.

Introduction

Background of the study

HYPERTENSION

Significance of the study:

Scope and limitation of the study
Goal and objectives:
Overview of disease
Anatomy and physiology of affected system

II. Biographic data

Name: Patient “s”
Address: Poblacion, Angat, Bulacan
Age: 56
Gender : Male
Civil status: Married
Educational level: High school Undergraduate
Religious affiliation: Roman Catholic
Occupation: Farmer

III. Nursing history

Past Health history

1. Childhood illness – chicken pox
2. Immunizations - fully immunized
3. Allergies - Peanuts
4. Accidents – Vehicular accident in right arm
5. Hospitalizations -
6. Medications used or currently taken

History of present illness

What happened to patient prior to hospitalization?
The patient ate fatty foods in the wedding of her daughter that causes
increase his blood pressure.

Sign and symptoms observed prior to hospitalization

The patient experienced dizziness, body malaise, discomfort, facial
grimace.
Medication given prior to hospitalization
Not applicable
 Family history
Hereditary disease of family
According to the patient his father and his grandfather had hypertension
IV. Activities of daily living

Before Actual Interpretation and

ADL
hospitalization hospitalization analysis
Nutrition
Elimination
activity
Hygiene
Substance use
Sleep and rest
Sexual activity

V. Physical assessment

Normal Actual findings Interpretation and

analysis

1. General
Appearance
 Mood and affect
 Signs of distress
 Posture
 Body Movement
 Hygiene and grooming
 Types of clothing
 Quantity and quality of
speech
 Relevance and
organization of thoughts

Vital signs
Body temp 36.5°C-37.5°C 36.9°C
Pulse rate 60-100 BPM 110 BPM
Respiratory rate 16-20 BPM 30 BPM
Blood pressure 120/80mmHg 150/100 mmHg
VII. Drug study

Nursing
Generic / Dosage / Classificatio Contraindica Side
Indication Responsibiliti
Trade name Frequency n tion effects
es

VIII. Pathophysiology

IX. Prioritization

Nursing problem Cues Justification

Hypertension Tachypnea, Pallor, Tachycardia The patient experienced this
Dizziness, Discomfort, Body cues due to increase blood
Malaise pressure.

BP : 150/100
RR : 30
PR : 110

X. NCP

Assessment Diagnosis Inference Planning intervention Rationale Evaluation