Assessment Subjective: Daughter reported patient exhibited mood swings and periods of confusion. Masakit ang ulo ko.

as verbalized by the client

Diagnosis Ineffective tissue perfusion related to narrowing of the arterial blood vessels

Rationale Artherosclerosis leads to increased cardiac output which injures the endothelial cells of the arteries and the action of prostaglandins. Vasoconstriction occurs and blood pressure increases.

Planning Short-Term: After 4 hours of nursing interventions, the client will be able to identify 3 examples (e.g. flexion, extension, deep breathing exercises) of treatments exercises and medications and her BP will decrease from 140/90 to 130/80

Intervention

Rationale

Evaluation Short-Term: Goal Met. After 4 hours of nursing interventions, the client was able to verbalize the knowledge of the treatment and her BP decreased from 140/90 to 130/80 mmHg.

-Monitored -To know the vital signs baseline of every 4 hours the clients vital signs -Maintained a clean and quiet environment -Instructed the client to rest on a semifowlers position -Instructed the client to eat low fat foods. -Peaceful environment promotes rest -Semifowlers position promotes relaxation -To reduce edema that may active angiotensinaldosterone system

Objective: -Weak pulses -Irritability -Restlessness -BP = 140/90 mmHg -PR = 60 bpm

Long-Term: Goal Met. After 2 days of nursing Long-Term: interventions, After 2 days -Deep the clients of nursing breathing pulse rate interventions, -Instructed exercises also and rhythm the clients the client to promotes went back to pulse rate do deep relaxation normal and and rhythm breathing she had the will be back exercises -To control ability to within BP and tolerate normal limits prevent other activity. and she will Administered complications have the Nimotop 1 ability to tab BID tolerate activity.