Anda di halaman 1dari 1

Assessment Nursing Dx Inference Planning Nursing Rationale Evaluation

Intervention
Cues > Ineffective > Increased After 4 hours > Monitored blood > To know the > After 4
(Subjective) tissue perfusion cardiac output of nursing pressure every base line of BP hours of
> “Nahihilo ako” as related to that injures the intervention 4hours. nursing
verbalized vasoconstriction endothelial cells the pt blood intervention
of blood of the arteries pressure will > Instructed to > Sodium tends the patient’s
(Objective) vessels. and the action decrease from have enough rest on to be excreted blood pressure
 PR = 85 bpm of 160/ 100mmHg semi fowlers at a faster rate. was decreased
 RR = 30 bpm prostaglandins. to position. from
 160/100mmHg Vasoconstriction 120/80mmHg. > To reduce 160/100mmHg
occurs and blood > Instructed to eat edema that may to
pressure low fat and low salt activate renin 140/90mmHg.
increases. diet. angiotensin-
aldosterone
system.

> To control the


> Administered BP and to avoid
anti- hypertensive other
drug as ordered. complications.