Assessment Nursing NURSING

Scientific CARE PLANInterventions

Planning Rationale Evaluation
Diagnosis Explanation
S: “parang Decreased Hypertensive The patient will  establish rapport  to facilitate NPI. Patient
nararamdaman ko Cardiac output cardiovascular participate in  place the client in  to prevent participated in
ung tibok ng puso a comfortable backaches or
ko” as verbalized by
r/t altered heart disease also activities that activities that
position muscle aches.
the patient. rate, rhythm, known as reduce the  monitor and  to note any
reduced the
and reports of hypertensive workload of the record vital signs significant changes workload of the
O: palpitations. heart disease heart. that may be brought heart.
 hooked to O2 occurs due to about by the
inhalation @ 1LPM  Assess skin color disease
the complication
 on HGT and temperature.  Cold, clammy
monitoring of hypertension
skin is secondary
 on low or high blood to compensatory
cholesterol, low pressure. In this increase in
sugar diet condition the sympathetic
 c body malaise workload of the nervous system
 s chest pain stimulation and
heart is
 s DOB low cardiac
increased  Assess output and
 c bradycardia (40
BPM) manifold and peripheral pulses. desaturation.
 c weak and with time this  Pulses are weak
thready pulse causes the heart  Assess fluid with reduced
 c decreased muscles to balance and cardiac output.
peripheral pulses weight gain.  Compromised
thicken. The
 ambulatory c regulatory
heart continues mechanisms may
assistance
pumping blood result in fluid and
 afebrile (36.8 oC)
against this sodium retention.
increased Body weight is a
more sensitive
pressure and indicator of fluid
over a period of or sodium
time the left retention than
ventricle of the  Assess response intake and
heart enlarges to increased output.
and this in turn activity.
 Physical
causes the blood activity increases
pumped by heart the demands
to reduce. placed on the
heart; fatigue and
exertional
dyspnea are
 Assess for chest common problems
pain. with low cardiac
output states.
 This indicates
 promote adequate an imbalance
rest by decreasing between oxygen
stimuli, providing supply and