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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.
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 or eliminate caffeine like in tea, coffee, cola and chocolates. Stress importance of accomplishing daily rest periods.
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
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.
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
Rationale
Evaluation
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.
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.