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Patient : Saballa, Susan Diagnosis: CVD ASSESSMENT DIAGNOSIS INFERENCE Subjective: pabigla biglang tumataas ang BP niya, as verbalized

by the watcher. Objective: >skin warm and moist to touch >dysnea occurrences upon exertion >Blood Pressure ranging from 120/90 to 200/130 >increased peripheral vascular resistance > VS taken as follows: T: 36.5 C PR: 96 BPM RR: 20 CPM BP: 180/130 mm/Hg Ineffective tissue perfusion related to vasoconstrict ion of blood vessels Increased Cardiac Output that injures the endothelial cells of the arteries and the action of prostaglandins. Vasoconstriction occurs and blood pressure increases

PLANNING STG: After 8 hrs of nursing interventions, the client will have no elevation in blood pressure above normal limits and will maintain blood pressure within acceptable limits. LTG: After 6 days of nursing interventions, the client will maintain adequate cardiac output and cardiac index.

INTERVENTION 1.Monitor BP every 1-2 hours, or every 15 minutes during administration of adrenergic agonist drugs. 2. Suggest frequent position changes. 3. Encourage patient to decrease intake of caffeine, cola and chocolates. 4. Observe skin color, temperature, capillary refill time and diaphoresis. 5. Auscultate heart tones. 6. Administer medicines as prescribed by the physician. 7. Instruct client & family on fluid and diet requirements and restrictions of sodium. 8. Instruct client and family on medications, side effects, contraindications and signs to report.

RATIONALE 1. Changes in BP may indicates changes in patient status requiring prompt attention. 2. It may decreases peripheral venous pooling that may be potentiated by vasodilators and prolonged sitting or standing. 3. Caffeine is a cardiac stimulant and may adversely affect cardiac function. 4. Peripheral vasoconstriction may result in pale, cool, clammy skin, with prolonged capillary refill time due to cardiac dysfunction and decreased cardiac output. 5. Hypertensive patients often have S4 gallops caused by atrial hypertrophy. 6. To promote wellness. 7. Restrictions can assist with decrease in fluid retention and hypertension, thereby improving cardiac output. 8. Promotes knowledge and compliance with drug regimen.

Mercado, Sean Derick C. January 30 2013 EVALUATION STG: After 8 hrs of nursing interventions, the client had no elevation in blood pressure above normal limits and had maintained blood pressure within acceptable limits. Latest BP of 120/90 Goal was met. LTG: After 6 days of nursing interventions, the client maintained an adequate cardiac output and cardiac index. Goal was met.