Client a Plan Care to Address the Health Conditions, Needs, Problems and Issues

 

ASSESSMENT

Subjective Data

“Maglisud kog ginhawa ma’am kay mosakit akong dughan unya naay time na malipong rakog kalit”, as verbalized by the patient.

 

Objective Data

BP: 140/100

Pulse Rate: 110 bpm

Respiratory Rate: 18 cpm

O2 saturation: 99%

·         Chest pain

·         Difficulty breathing

·         Sweating

·         Irregular heartbeat

·         Fatigue

·         Dizziness

      

DIAGNOSIS

Problem Identified

·         Elevated blood pressure

Nursing Diagnostic Statement

• Risk for Decreased Cardiac Output related to Increased vascular resistance

 

Cause Analysis

Blood pressure is the product of cardiac output multiplied by peripheral resistance. Hypertension can result from an increase in cardiac output (heart rate multiplied by stroke volume), an increase in peripheral resistance, or both. It happens when your blood moves through your arteries at a higher pressure than normal. Many different things can cause high blood pressure. If your blood pressure gets too high or stays high for a long time, it can cause health problems. Uncontrolled high blood pressure puts you at a higher risk for stroke, heart disease, heart attack, and kidney failure.

Source: https://familydoctor.org/condition/high-blood-pressure/

 

PLANNING

Short Term Objectives

After 8 hours of nursing interventions, patient will:

 

• Participate in activities that reduce BP/cardiac workload.
• Maintain BP within individually acceptable range.
• Demonstrate stable cardiac rhythm and rate within patient’s normal range.

 

Long Term Objectives

After three days of nursing interventions, the patient will:

• Participate in activities that will prevent stress (stress management, balanced activities and rest plan).

 

INTERVENTIONS

Independent

1.      Monitor and record BP. Measure in both arms and thighs three times, 3–5 min apart while the patient is at rest, then sitting, then standing for initial evaluation. 

2.      Provide calm, restful surroundings, minimize environmental activity and noise. Limit the number of visitors and length of stay.

3.      Maintain activity restrictions (bed rest or chair rest); schedule uninterrupted rest periods; assist patient with self-care activities as needed.

4.      Provide comfort measures (back and neck massage, the elevation of head).

5.       Instruct in relaxation techniques, guided imagery, distractions.

6.      Monitor response to medications to control blood pressure.

7.       Note dependent and general edema.

8.       Implement dietary sodium, fat, and cholesterol restrictions as indicated.

 

Dependent/Collaborative

  Administer medications as prescribed by the doctor.

To Coordinatte with the nutritionist for the proper diet.

RATIONALE

1.  Vital signs monitoring is crucial for living a long and healthy life. Vitals gives us a glimpse into our overall wellbeing. 

 2. It helps lessen sympathetic stimulation; promotes relaxation.

3. Lessens physical stress and tension that affect blood pressure and the course of hypertension.

4. Decreases discomfort and may reduce sympathetic stimulation.

5. Can reduce stressful stimuli, produce a calming effect, thereby reducing BP.

6. Because of side effects, drug interactions, and patient’s motivation for taking antihypertensive medication, it is important to use the smallest number and lowest dosage of medications.

7.May indicate heart failure, renal or vascular impairment.

8.These restrictions can help manage fluid retention and, with the associated hypertensive response, decrease myocardial workload.

9.Facilitate proper taking of the medication.

10.To know the proper diet or eating to manage the symptoms of a disease or chronic condition.

EVALUATION

 

Short Term Objectives

After 8 hours of nursing interventions, patient was able to:

• Participate in activities that reduce BP/cardiac workload.
• Maintain BP within individually acceptable range.
• Demonstrate stable cardiac rhythm and rate within patient’s normal range.

 

Long Term Objectives

After three days of nursing interventions, the patient was able to:

• Participate in activities that will prevent stress (stress management, balanced activities and rest plan).