NURSING CARE PLAN Patient Name: Mrs. G.G.D.

Diagnosis: Hypertension Assessment Subjective: Risk for injury Maulawak as related to verbalized by the altered patient. physical mobility Objective: secondary to dizziness as Weak looking manifested by Prefers to lie the complaints. down Decreased attention Self-focused The patient will be free from injury during his confinement in the hospital, especially during dizzy spell. Monitor vital signs. To provide baseline data for future evaluation and comparison To ensure patients safety, primarily preventing patient from falling from bed. To promote rest and comfort. Goal met. Patient was free from injury all throughout the confinement period. Nursing Diagnosis Planning Intervention Rationale Evaluation

Raise side rails.

Provide noise free environment.

Patient Name: Mrs. G.G.D. Diagnosis: Hypertension Assessment Subjective: Acute pain Nagsakit ulok as related to verbalized by the increased patient. cerebrovascular pressure as evidence by reluctant to Objective: move head and verbal reports. Restlessness Irritability Sleep disturbance Self-focused Nursing Diagnosis Planning Intervention Rationale Evaluation

After 8 hours of nursing interventions, the patient will verbalized relief from pain.

Determine and document presence of possible pathophysiological and psychological cause of pain. Note clients attitude toward pain and use of pain medications Monitor skin color and vital signs.

To asses etiology/precipi tating contributory factors. To evaluate clients response to pain To promote nonpharmacolo gical pain management. To prevent fatigue.

Goal met. The patient report pain is relieved or controlled.

Instruct and encourage use of relaxation technique and encourage adequate rest periods.

Patient Name: Mrs. G.G.D. Diagnosis: Hypertension Assessment Subjective: Apay ngata ta agulaw ak? as verbalized by the patient. Objective: Agitated behavior Inaccurate follow through instruction s. With blood pressure of 180/100. Nursing Diagnosis Risk for prone behavior related to lack of knowledge about the disease. Planning After 8 hours of nursing intervention s, the patient will verbalized understandi ng of the disease process and treatment regimen. Intervention Define and state the limits of desired BP. Explain hypertension and its effect on the heart, blood vessels, kidney and brain. Rationale Provides basis for understanding elevations of BP, and clarifies misconceptions and also understanding that high BP can exist without symptom or even when feeling well. The risk factors have been shown to contribute to hypertension. Evaluation Goal met. The patient verbalizes understandin g on the disease process and treatment regimen.

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 followup appointment.

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

Suggest frequent position changes, leg exercise when lying down.

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.

Help patient identify sources of sodium intake.

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

Alternating rest

and activity increases tolerance to activity progression.

Patient Name: Mrs. G.G.D. Diagnosis: Hypertension Assessment Subjective: Activity Agkakapsut ak, Intolerance ken, naglaka ak related to body lang nga weakness mabanbanug as verbalized by the patient. Objective: Body weakness Fatigue V/S: BP=160/1 00 PR=55 bpm After rendering nursing care interventions, the patient will be able to report measurable increase in energy and will participate in necessary desired activities. Nursing Diagnosis Planning Intervention Rationale Evaluation

Assessed response to activity including v/s Provided patient with positive atmosphere Encouraged patients participation in planning of activities Assisted patient in carrying out self-care activities Encouraged patient to carry out ADLs. Placed patient on a position of comfort.

To identify causative factors

To assist pt. to deal with manages factors that contribute to fatigue. To provide pt. with a sense of control To improve mobility.

After rendering nursing care interventions, the patient was able to report measurable increase in energy and was able to participate in necessary desired activities.

To enhance motivation. To maintain body alignment.