Escolar Documentos
Profissional Documentos
Cultura Documentos
Alexandria Rose
Name
11/21/15
Date
6.26.2012
6.26.2012
Etiology
General Weakness
Gradual, worsening immobility and inactivity. According to the son, the patient has been laying
Etiology
Hypertension
Persistent systolic BP of >140 or diastolic BP>90 without blood pressure medication (Today,
162/76). This indicates increased peripheral vascular resistance, which causes increased work of the heart. Patient also
complains of occasional palpitations and angina.
Problem
Etiology
6.26.2012
E: General
Weakness
S: Gradual,
worsening
immobility and
inactivity.
According to the
son, the pt has
been laying on
the couch for the
majority of the
past 4 days.
6.26.2012
Expected
Outcomes
Client will verbalize
understanding of
treatment/therapy
regimen (Doenges,
Moorhouse, Murr
pg. 865)
Evaluation of
expected
outcomes
Goal Met
AEB client states
she understands
that in order to
regain her normal
mobility, she needs
to work with PT
during in home
care.
Nursing Interventions
Rationale
Evidence-based?
Evaluation of
Interventions
1. Rationale: Systematic
inspection can identify
developing changes and
promotes early intervention,
thus reducing likelyhood of
progression to skin breakdown
(Doenges, Moorhouse, Murr pg.
866).
1. Goal met.
AEB client identified 2
moles that had changed
in appearance.
2. Rationale: To enhance
venous return and reduce
edema formation (Doenges,
Moorhouse, Murr pg. 868).
2. Goal met.
AEB client's legs were
elevated when sitting in
the bedside chair.
3. Goal met.
AEB client repeated
back the importance of
thoroughly drying moist
areas, such as under
her breasts.
4. Discharge Planning:
Encourage abstinence from
smoking.
E: Hypertension
Expected
Outcomes
Nursing
Interventions
Goal partially
met.
Blood pressure is
WNL after blood
pressure
medication is
administered,
5
Rationale
Evidence-based?
Evaluation of
Interventions
1. Goal met.
AEB vital sign check and
neurological assessment
were performed and
recorded.
2. Intervene:
Administer blood or
fluid replacement,
antibiotics, diuretics,
inotropic drugs,
antidysrhythmics,
steroids, vasopressors,
and/or dilators, as
indicated. Evaluate
response.
3. Teach: Provide for
diet restrictions (e.g.
low-sodium, bland,
soft, low-calorie/fat
diet with frequent small
feedings) as needed.
2. Goal met.
AEB Losartan (a
vasodilator) was
administered and blood
pressure returned to
acceptable range.
3. Rationale: To maintain
adequate nutrition and fluid
balance (Doenges, Moorhouse,
Murr pg. 177).
peripheral pulses
are +2 regular
rate/rhythmbut
I&O were not
ordered
4. Discharge Planning:
Discuss significant
signs/symptoms that
require prompt
reporting to healthcare
provider (e.g. muscle
cramps, headaches,
dizziness, skin rashes).
6.26.2012
4. Goal met.
AEB patient states she
will report any
palpitations, skin rashes,
muscle cramps or
dizziness to her care
provider.
TEACHING PLAN
Teaching Topic
Causes of HTN and specific lifestyle changes to lower blood pressure.
Clients Current Understanding of Topic
Client understands that her blood pressure is high, but is unaware of risk factors or causes.
Content Taught (provide content outline or attach content from reliable source)
The education focused on healthy meal choices and smoking cessation. The client was taught
that low sodium foods have potential to lower blood pressure. The client was also taught that her
smoking habits are likely a main cause of her current HTN.
Evaluation of Learning
The client seemed to understand the teaching, however she still seemed reluctant to make further
efforts to quit smoking.
Resources:
http:www.jblearning.com/samples/0763751375/46436_CH05_000_000.pdf
http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/lifestyle-home-remedies/con20019580?p=1
Ackley and Ladwig: Nursing Diagnosis Handbook. Mosby
Readiness for enhanced knowledge
6.26.2012
Deficient Knowledge
Ineffective Health Maintenance
Ineffective Therapeutic Regimen Management
Fundamentals of Nursing textbook
6.26.2012