NURSING CARE PLAN FOR HYPERTENSION

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Decreased STG: 1.monitor BP every1-2 1. changes in BP may indicates STG:
“madalas ako Cardiac Output After 6 hrs of hours, or every5 changes in patient status After 6 hrs of nursing
mahilo”, as verbalized r/t malignant nursing minutes during active requiring prompt attention. interventions, the client had
by the patient. hypertension as interventions, the titration of vasoactive no elevation in blood
manifested by client will have no drugs. pressure above normal limits
Objective: decreased stroke elevation in blood 2. monitor ECG for 2. decrease in cardiac output and will maintain blood
>lethargic volume. pressure above dysrhythmias, may result in changes in pressure within acceptable
>decreased cardiac normal limits and conduction defects and cardiac perfusion causing limits.
output will maintain blood for heart rate. dysrhythmias. Goal was met.
>decreased stroke pressure within
volume acceptable limits. 3. suggest frequent 3. it may decrease peripheral LTG:
>increased peripheral position changes. venous pooling that may be After 5 days of nursing
vascular resistance LTG: After 5 days potentiated by vasodilators interventions, the client
>VS taken as follows: of nursing and prolonged sitting or maintained an adequate
T: 37.2 interventions, the standing. cardiac output and cardiac
PR: 83 client will maintain 4.encourage patient to 4. caffeine is a cardiac index.
RR: 18 adequate cardiac decrease intake of stimulant and may adversely Goal was met.
BP: 180/100 output and cardiac caffeine, cola and affect cardiac function.
index. chocolates.

5. observe skin color, 5. peripheral vasoconstriction

temperature, capillary may result in pale, cool,
refill time and clammy skin, with prolonged
diaphoresis. capillary refill time due to
cardiac dysfunction and
decreased cardiac output.

6.auscultate heart 6. hypertensive patients often

tones. have S4 gallops caused by
atrial hypertrophy.

7. administer 7. to promote wellness.

medicines as
 prescribed by the
physician.

8. instruct client 8. restrictions can assist with

&family on fluid and decrease in fluid retention and
diet requirements and hypertension, thereby
restrictions of sodium. improving cardiac output.

9. instruct client and 9. promotes knowledge and

family on medications, compliance with drug regimen
side effects,
contraindications and
signs to report.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Ineffective Tissue STG: After 8 hrs 1. monitor VS at least 1.to monitor baseline STG: After 8 hrs of
“ Laging sumasakit ang Perfusion: of nursing q 1-2 hrs and prn. data. nursing interventions,
aking ulo at parang Cardiopulmonary, interventions, 2. encourage patient blood pressure
nanlalabo ang aking Gastrointestinal blood pressure to decrease intake of 2. caffeine is a cardiac maintained within set
paningin”, as verbalized by and Peripheral r/t will be within caffeine, cola and stimulant and may parameters for the
the patient. hypertension and set parameters chocolates. adversely affect cardiac client.
decreased for the client. function. Goal was met.
Objective: cardiac output as LTG: After 6 3. administer LTG: After 6 days of
 Tachycardia manifested by days of nursing vasoactive drugs and 3. these drugs have rapid nursing interventions,
 Shortness of breath blurred vision interventions, titrate as ordered to action and may decrease the client had an
 Rales and increased the client will maintain pressures at the blood pressure too adequate tissue
 Restlessness blood pressure. have an set parameters for rapidly, resulting in perfusion to his body
 Cool, clammy skin adequate tissue patient. complications. systems.
 Optic disc perfusion to his 4. observe for Goal was met.
papilledema body systems. complaints of blurred 4. may indicate cyanide
vision, tinnitus or toxicity from increasing
confusion. intracranial pressure.
5. monitor I&O
status. 5. I&O will give an
indication of fluid balance
 or imbalance, thus
allowing for changes in
treatment regimen when
required.

6. monitor for sudden 6. may indicate dissecting

onset of chest pain. aortic aneurysm.
7. monitor ECG for 7. decreased perfusion
changes in rate, may result in dysrhythmias
rhythm, dysrhythmias caused by decrease in
and conduction oxygen.
defects.
8. observe 8.Bedrest promotes
extremities for venous statis which can
swelling, erythema, increase the risk of
tenderness and pain. thromboembolus
Observe for formation. If treatment is
decreased peripheral too rapid and aggressive in
pulses, pallor, decreasing the blood
coldness and pressure, tissue perfusion
cyanosis. will be impaired and
ischemia can result.
9. instruct client in
signs/symptoms to 9. promotes knowledge
report to physician and compliance with
such as headache treatment. Promotes
upon rising, increased prompt detection and
blood pressure, chest facilitates prompt
pain, shortness of intervention.
breath, increased
heart rate, visual
changes, edema,
muscle cramps and
nausea and vomiting.