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ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

Subjective:
madalas ako
mahilo, as
verbalized by the
patient.

Decreased Cardiac
Output r/t malignant
hypertension as
manifested by
decreased stroke
volume.

STG:
After 6 hrs of
nursing
interventions, the
client will have no
elevation in blood
pressure above
normal limits and
will maintain blood
pressure within
acceptable limits.

1.monitor BP every
1-2 hours, or every
5 minutes during
actve titration of
vasoactive drugs.
2. monitor ECG for
dysrrhythmias,
conduction defects
and for heart rate.

Objective:
>lethargic
>decreased cardiac
output
>decreased stroke
volume
>increased
peripheral vascular
resistance
>VS taken as
follows:
T: 37.2
PR: 83
RR: 18
BP: 180/100

LTG:
After 5 days of
nursing
interventions, the
client will maintain
adequate cardiac
output and cardiac
index.

RATIONALE

1. changes in BP
may indicates
changes in patient
status requiring
prompt attention.
2. decrease in
cardiac output may
result in changes in
cardiac perfusion
causing
dysrhythmias.
3. suggest frequent
3. it may decreases
position changes.
peripheral venous
pooling that may be
potentiated by
vasodilators and
prolonged sitting or
standing.
4.encourage patient 4. caffeine is a
to decrease intake of cardiac stimulant
caffeine, cola and
and may adversely
chocolates.
affect cardiac
function.
5. observe skin
5. peripheral
color, temperature,
vasoconstriction
capillary refill time may result in pale,
and diaphoresis.
cool, clammy skin,
with prolonged
capillary refill time

EVALUATION
STG:
After 6 hrs of
nursing
interventions, the
client had no
elevation in blood
pressure above
normal limits and
will maintain blood
pressure within
acceptable limits.
Goal was met.
LTG:
After 5 days of
nursing
interventions, the
client maintained an
adequate cardiac
output and cardiac
index.
Goal was met.

6.auscultate heart
tones.

7. administer
medicines as
prescribed by the
physician.
8. instruct client &
family on fluid and
diet requirements
and restrictions of
sodium.

due to cardiac
dysfunction and
decreased cardiac
output.
6. hypertensive
patients often have
S4 gallops caused
by atrial
hypertrophy.
7. to promote
wellness.

8. restrictions can
assist with decrease
in fluid retention
and hypertension,
thereby improving
cardiac output.
9. instruct client and 9. promotes
family on
knowledge and
medications, side
compliance with
effects,
drug regimen.
contraindications
and signs to report.

ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective:
Laging sumasakit ang
aking ulo at parang
nanlalabo ang aking
paningin, as
verbalized by the
patient.

Ineffective Tissue
Perfusion:
Cardiopulmonary,
Gastrointestinal and
Peripheral r/t
hypertension and
decreased cardiac
output as
manifested by
blurred vision and
increased blood
pressure..

STG:
After 8 hrs of
nursing
interventions,
blood pressure will
be within set
parameters for the
client.

1. monitor VS at
least q 1-2 hrs and
prn..
2. encourage patient
to decrease intake
of caffeine, cola
and chocolates.

1.to monitor
baseline data.

STG:
After 8 hrs of
nursing
interventions, blood
pressure
maintained within
set parameters for
the client.
Goal was met.

Objective:
Tachycardia
Shortness of
breath
>rales
Restlessness
Cool, clammy
skin
Optic disc
papilledema
Increased blood
pressure.

LTG:
After 6 days of
nursing
interventions, the
client will have an
adequate tissue
perfusion to his
body systems.

.3. administer
vasoactive drugs
and titrate as
ordered to maintain
pressures at set
parameters for
patient.
4. observe for
complaints of
blurred vision,
tinnitus or
confusion.
5. monitor I&O
status.

2. caffeine is a
cardiac stimulant
and may adversely
affect cardiac
function.
3. these frugs have
rapid action and
may decrease the
blood pressure too
rapidly, resulting in
complications.
4. may indicate
cyanide toxicity
from increasing
intracranial
pressure.
5. I&O will give an
indication of fluic
balance or
imbalance, thus
allowing for
changes in
treatment regimen
when required.

LTG:
After 6 days of
nursing
interventions, the
client had an
adequate tissue
perfusion to his
body systems.
Goal was met.

6. monitor for
sudden onset of
chest pain.
7. monitor ECG for
changes in rate,
rhythm,
dysrhythmias and
conduction defects.
8. observe
extremities for
swelling, erythema,
tenderness and
pain. Observe for
decreased
peripheral pulses,
pallor, coldness and
cyanosis.

6. may indicate
dissecting aortic
aneurysm.

7. decreased
perfusion may
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 pressire,
9. instruct client in
tissue perfusion
signs/symptoms to
will be impaired
report to physician
and ischemia can
such as headache
result.
upon rising,
9. promotes
increased blood
knowledge and
pressure, chest pain, compliance with
shortness of breath, treatment.
increased heart rate, Promotes prompt

visual changes,
edema, muscle
cramps and nausea
and vomiting.

detection and
facilitates prompt
intervention.

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