Assessment Explanation Planning Interventions Rationale Evaluation

Subjective: Inadequate blood pumped by

Objective: the heart to meet the STG: 1.monitor BP every 1-2 1. changes in BP may STG:
 lethargic metabolic demands of the After 6 hrs. of nursing hours, or every 5 minutes indicates changes in After 6 hrs.++ of nurs
 decreased body. Vulnerable to interventions, the client during active titration of patient status requiring interventions, the clie
cardiac output inadequate blood pumped by will have no elevation in vasoactive drugs. prompt attention. had no elevation in bl
 decreased stroke the heart to meet the blood pressure above 2. monitor ECG for 2. decrease in cardiac pressure above norma
volume metabolic demands of the normal limits and will dysrhythmias, conduction output may result in limits and will mainta
 increased body, which may maintain blood pressure defects and for heart rate. changes in cardiac blood pressure within
peripheral compromise health within acceptable limits. perfusion causing acceptable limits.
vascular 3. suggest frequent position dysrhythmias. Goal was met.
resistance LTG: changes. 3. it may decrease
 rubbing her mid- After 5 days of nursing peripheral venous pooling LTG:
chest, interventions, the client that may be potentiated After 5 days of nursin
will maintain adequate by vasodilators and interventions, the clie
 grimacing
cardiac output and prolonged sitting or maintained an adequa
diaphoretic
cardiac index. 4.encourage patient to standing. cardiac output and
 Lungs sounds. decrease intake of caffeine, cardiac index.
 color is pale cola and chocolates. 4. caffeine is a cardiac Goal was met.
except around stimulant and may
her adversely affect cardiac
 lips which are 5. observe skin color, function.
bluish temperature, capillary refill 5. peripheral
>VS taken as follows: time and diaphoresis. vasoconstriction may
 Blood Pressure- result in pale, cool,
200/110; clammy skin, with
 Pulse-128 beats prolonged capillary refill
per minute; time due to cardiac
 Respirations- 26 dysfunction and
 per minute; decreased cardiac output.
Temperature- 6.auscultate heart tones.
99.8; Saturation
of Oxygen-86%
on room air; 6. hypertensive patients
 Pain level 9/10 7. administer medicines as often have S4 gallops
Nursing Diagnosis prescribed by the physician. caused by atrial
Decreased Cardiac 8. instruct client & family hypertrophy.
Output r/t malignant on fluid and diet
hypertension as requirements and
manifested by decreased restrictions of sodium. 7. to promote wellness.
stroke volume.
8. restrictions can assist
9. instruct client and family with decrease in fluid
on medications, side retention and
effects, contraindications hypertension, thereby
and signs to report. improving cardiac output.

9. promotes knowledge
and compliance with drug
regimen.

ASSESSMENT EXPLANATION PLANNING INTERVENTIONS RATIONALE

EVALUATION

Subjective: Ineffective Tissue STG: 1. monitor VS 1.to monitor baseline data.

“ Laging sumasakit Perfusion: After 8 hrs of at least q 1-2
ang aking ulo at Cardiopulmonary, nursing hrs and prn.. 2. caffeine is a cardiac
parang nanlalabo Gastrointestinal and interventions, blood 2. encourage stimulant and may
ang aking Peripheral r/t pressure will be patient to adversely affect cardiac
paningin”, as hypertension and within set decrease intake function.
verbalized by the decreased cardiac parameters for the of caffeine, 3. these frugs have rapid
patient. output as client. cola and action and may decrease the
manifested by chocolates. blood pressure too rapidly,
Objective: blurred vision and LTG: resulting in complications.
 Tachycardia increased blood After 6 days of .3. administer
 Shortness of pressure. nursing vasoactive 4. may indicate cyanide
breath interventions, the drugs and toxicity from increasing
 >rales client will have an titrate as intracranial pressure.
 Restlessnes adequate tissue ordered to 5. I&O will give an
s perfusion to his maintain indication of fluic balance
 Cool, body systems. pressures at set or imbalance, thus allowing
clammy parameters for for changes in treatment
skin patient. regimen when required.
 Optic disc 4. observe for
papilledema complaints of
 Increased blurred vision, 6. may indicate dissecting
blood tinnitus or aortic aneurysm.
pressure. confusion.
5. monitor I&O 7. decreased perfusion may
status. result in dysrhythmias
caused by decrease in
oxygen.
8.Bedrest promotes venous
 statis which can increase
the risk of thromboembolus
formation. If treatment is
too rapid and aggressive in
decreasing the blood
6. monitor for pressire, tissue perfusion
sudden onset of will be impaired and
chest pain. ischemia can result.
9. promotes knowledge and
7. monitor ECG compliance with treatment.
for changes in Promotes prompt detection
rate, rhythm, and facilitates prompt
dysrhythmias intervention.
and conduction
defects.
8. observe
extremities for
swelling,
erythema,
tenderness and
pain. Observe
for decreased
peripheral
pulses, pallor,
coldness and
cyanosis.
9. instruct
client in
signs/symptom
s to report to
physician such
as headache
upon rising,
increased blood
pressure, chest
pain, shortness
of breath,
increased heart
rate, visual
changes,
edema, muscle
cramps and
nausea and
vomiting.
 Assessment Explanation Planning Interventions Rationale Evaluation
Subjective Ineffective tissue Perfusion At my 8hours of > monitor VS at >to monitor  After my 8hours of nursing
r/t hypertension and least q 1-2 hrs. baseline data care, goal partially met as
decreased cardiac output as nursing care, the pt. and prn. evidenced by, The patient:
manifested by increased will :
blood pressure. > encourage > caffeine is a cardiac > Participate in activities that
Objective patient to decrease stimulant and may reduce BP/cardiac workload.
>Participate in
-Tachycardia intake of caffeine, adversely > Participate in activities that
-Shortness of  breath activities that reduce cola and Affect cardiac function. will prevent stress (stress
-Restlessness BP/cardiac workload. chocolates. management, balanced
-Cool clammy skin activities and rest plan).
>Maintain BP within
-Increased  >administer  > these drugs have
blood pressure 200/110 individually vasoactive drugs Rapid action and
acceptable range. and titrate as May decrease the blood
>Demonstrate stable ordered to pressure too
A-Risk for decreased maintain rapidly, resulting in
cardiac output cardiac rhythm and pressures at complications.
secondary to End rate within patient’s set parameters for
Stage Renal Disease normal range. patient.
(ESRD) >may indicate
>Participate in > observe cyanide toxicity
activities that will for complaints of from increasing
prevent stress (stress blurred vision, intracranial
 management, balanced tinnitus pressure.
or confusion.
activities and rest
plan). > monitor I&O >I&O will give an
status. indication of fluid
balance or imbalance,
thus allowing
for changes in
treatment regimen
when required.

Assessment Explanation Planning Interventions Rationale Evaluation

SUBJECTIVE: Deficient After 8 hours of  Define and state  Provides basis for After 8 hours of
“Bakit kaya knowledge nursing the limits of understanding elevations of nursing interventions,
madalas sumsasakit ulo regarding interventions, the desired BP. BP, and clarifies the patient was able to
ko at nahihilo?” as condition, patient will Explain misconceptions and also verbalize understanding of the
verbalized by the therapeutic verbalize hypertension and understanding that high BP disease process and treatment regimen.
patient. regimen and understanding of its effect on the can exist without symptom
potential the disease process heart, blood or even when feeling well.
OBJECTIVE: complications and treatment vessels, kidney,  These risk factors have been
 Request for regimen. and brain. shown to contribute to
information. hypertension.
 Agitated behavior
 irritable  Assist the patient
 V/S taken as in identifying
follows: modifiable risk  Lack of cooperation is
factors like diet common reason for failure
T-99.0 high in sodium, of antihypertensive therapy.
BP-180/95 saturated fats and
SPO2- 90% cholesterol.
RR- 22  Decreases peripheral venous
PAIN LEVEL  Reinforce the pooling that may be
8/10 importance of potentiated by vasodilators
HR – 108 adhering to and prolonged sitting or
treatment standing.
regimen and
keeping follow  Two years on moderate low
up appointments. salt diet may be sufficient to
control mild hypertension.
 Suggest frequent
position changes,  Caffeine is a cardiac
leg exercises stimulant and may adversely
when lying affect cardiac function.
down.
 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.
Subjective: Risk for injury After 6 hrs of  Monitor vital signs  To obtain baseline for Goal met. Patient didn’t
“ nahihilo ako” related to nursing every 2 hours. comparison. acquire injury within the
as verbalized by absence of side interventions, the confinement.
the patient rails secondary client will not  Assess for muscle  To be able to know if
to dizziness acquire injury within strength. the patient can move
Objective: the confinement. according to want he
 bed has no needs.
side rails
 V/S taken  Instructed the watcher  To have close
as follows: to closely watch the monitoring and prevent
Are patient to prevent from from getting injury.
falling or slipping.
T-99.0
BP-180/95  Instructed patient to  To replace fluid loss
SPO2- 90% increase fluid intake and regain energy.
RR- 22 and adequate diet.
PAIN LEVEL
8/10  Stress importance of  Alternating rest and
HR – 108 accomplishing daily activity increases
rest periods. tolerance to activity
progression.