Cues Nursing Analysis Goals & Intervention Rationale Evaluation

Diagnosis Objectives
SUBJECTIVE: Risk for High blood Goal: The patient
Complaint of decreased pressure is a After 8 hour of was able to
dizziness. cardiac output common condition nursing demonstrate
r/t in which the force interventions, the stable cardiac
OBJECTIVE: vasoconstriction of the blood against patient will exhibit rhythm and
BP: 160/100 your artery walls is a decrease in blood rate within
mmHg high enough that it pressure that is patients
PR: 77 bpm may eventually within the patients normal range.
RR: 18cpm cause health acceptable range. YES ______
T: 38.1C problems, such as NO ______
heart disease. High Objective:
Pale palpebral blood pressure The patient will:
conjunctiva does not mean -Demonstrate -Monitor and record -Comparison of The patient
Pale nailbeds excessive stable cardiac BP. Measure in both pressures provides a was able to
Syncope emotional tension, rhythm and rate arms and thighs three more complete picture participate
although emotional within patients times, 35 min apart of vascular involvement in activities
Medical tension and stress normal range. while patient is at rest, or scope of problem. that reduce
Diagnosis: can temporarily then sitting, then Pulses in the legs and BP/cardiac
Atrial Flutter, increase blood standing for initial feet may be diminished, workload.
Anemia, CKD pressure. evaluation. Use correct reflecting effects of YES ______
http://nurseslabs.co cuff size and accurate vasoconstriction. S4 NO ______
m/6-hypertension- technique. Note heart sound is common
htn-nursing-care- presence, quality of in severely
plans/ central and peripheral hypertensive patients The patient
pulses. Auscultate heart because of the presence was able to
tones and breathe of atrial hypertrophy. take
sounds. Presence of crackles, medications
wheezes may indicate as indicated.
pulmonary congestion YES ______
secondary to NO ______
developing or chronic
 heart failure.
The patient
-Participate in -Provide comfort was able to
activities that measures. Instruct in -Decreases discomfort eat foods that
reduce BP/cardiac relaxation techniques, and may reduce are
workload. guided imagery, sympathetic appropriate to
distractions. stimulation. Can reduce her condition.
stressful stimuli, YES ______
produce calming effect, NO ______
thereby reducing BP.

-Take medications -Administer

as indicated. medications as ordered -Medications can help
by the physician. in the treatment and
management of
diseases.
-Will eat foods that -Implement dietary
are appropriate to sodium, fat, and -These restrictions can
her condition. cholesterol restrictions help manage fluid
as indicated. Encourage retention and, with
patient in eating more associated hypertensive
foods rich in K+, Ca+2, response, decrease
and Mg+2 such as leafy myocardial workload.
greens, berries, beets,
potatoes, skim milk,
oatmeal, and bananas.
(http://nurseslabs.com/6
-hypertension-htn-
nursing-care-plans/)