Assessment

SUBJECTIVE: Dati nga nangato ti blood pressure ko, as verbalized by the patient The patient reported dizziness, blurred vision and chest pain The patient complained bearable lower abdominal pain OBJECTIVE: conscious and coherent UTZ revealed staghorn calculi on left kidney V/S taken as follows T: 36.0 C P: 78 bpm R: 15 cpm BP: 130/100 mmHg Patient has a history of: Hypertension, Diabetes Mellitus, and Renal calculi The patient

Diagnosis
Decreased cardiac output related to increased peripheral vascular resistance secondary to hypertension as evidence by BP of 130/100, patient complaining of dizziness, blurred vision, and chest pain

Inference
Hypertension occurs when there is a change in arteriolar bed which increases peripheral vascular resistance thus, decreasing blood flow to organs.

Planning
After 8 hours of nursing interventions , the patient will be able to verbalize an absent of dizziness, blurred vision and chest pain and BP will be stabilized to 120/80

Intervention
Independent The nurse will assess the patients blood pressure and cardiac rhythm every hour until stable. The nurse will assess the patients chest pain level and blurred vision every 4 hours until absent. The nurse will educate the patient on how to consult with his doctor before stopping a medication. Promote adequate rest by decreasing stimuli and providing quiet environment. Provide for restrictive diet: low salt, low fat diet Collaborative: Administer antihypertensive medications (e.g. Clonidine), as prescribed.

Rationale
To monitor if medications and the dose is having a favorable effect. To ensure patients safety.

Evaluation
Goal Met: The patient was able to stabiliz e her blood pressure to 120/80 and dizzines s, blurred vision and chest pain were relieved .

To prevent rebound hypertension.

For the patient to be comfortable during the therapy. Salt retains water thus increasing blood volume and blood pressure. May be given to treat hypertension.

Anxiety related to threat to or change in health status secondary to renal calculi as manifested by verbalization of feelings of inadequacy, fear of unspecific

Anxiety is a feeling of nervousness or worry. This occurs when there is a sudden and unexpected incident that happens to a person.

After 8 hours of nursing interventions , the patient will appear relaxed and report anxiety is reduced to a manageable level and identifies healthy ways to deal with

Independent: Establish a therapeutic relationship, conveying empathy and unconditional positive regard. Encourage patient to express feelings. Acknowledge fear/anxiety. Do not reassure the patient that everything will be all right.

To build rapport and to calm the patient.

To be able for her to free her emotions. Re-assurance is not therapeutic because we are not in control over the situation.

Goal partiall y met: after 8 hours of nursing interven tions, the patient was able to appear relaxed

is anxious due to the operation needed for her renal calculi

consequence and tearfulness.

anxiety.

Provide comfort measures (e.g., calm environment, back rub, soft music). Assist patient to learn precipitating factors and new methods of coping with anxiety. Collaborative: Refer to physician for drug management program/alteration of prescription regimen. Independent: Observe for signs of infection and inflammation. Promote good hand washing by nurse and patient. Provide catheter or perineal care. Teach the female patient to clean from front to back after elimination. Keep the skin dry, linens dry and wrinkle free. Collaborative: Obtain specimen for culture and sensitivities as indicated.

To relax the patient and reduce anxiety. For the patient to easily cope up on the situation. Drugs may be used to reduce anxiety and calm the patient.

but still reported fear about her conditio n.

Risk for infection related to high glucose levels, decreased leukocyte function secondary to Type II Diabetes Mellitus

Type 2 diabetes mellitus occurs when the pancreas produces insufficient amounts of the hormone insulin and/or the body's tissues become resistant to normal or even high levels of insulin. This causes high blood glucose (sugar) levels, which can lead to a number of complications if untreated.

After 8 hours of nursing interventions , the patient will identify interventions to prevent or reduce risk of infection.

Patient may be admitted with infection or may develop nosocomial infection. Reduces the risk of cross-contamina-tion. Minimizes the risk for infection.

Peripheral circulation may be impaired, placing patient at increased risk for infection. Identifies organisms so that most appropriate drug therapy can be instituted.

Goal met: after 8 hours of nursing interven tions, the patient was able to identify interven tions to prevent or reduce risk of infectio n.

Republic of the Philippines University of Northern Philippines Tamag, Vigan City College of Nursing

Nursing Care Plan

In Partial Fulfilment of the Requirements in NCM 103A

Submitted to: Ms. Zielene Myrus Alzo, R.N., MAN Clinical Instructor

Submitted by: Alyssa Marie A. Aludino BSN III-Chamomile June 22, 2012