Top 10 Nursing Care Plan

1. Decreased cardiac output related to disease process.

2. Risk for fall related to incorrect use of assistive device (crutches) and visual alteration
3. Knowledge deficit related to lack of information about the disease process and self-care
4. Ineffective health maintenance related to cultural beliefs
5. Imbalance nutrition: More than body requirements related to poor dietary habits.
6. Risk for activity intolerance related to decrease strength of the lower extremities
7. Risk- prone health behavior related to negative attitude toward healthcare
8. Impaired physical mobility related to body weakness and muscle aches
9. Fatigue related to effects of hypertension and stresses of daily life
10. Ineffective self-management relate to knowledge deficit

Nursing Diagnosis 1: Decreased cardiac output related to disease process

Cues/Evidences
Outcome Criteria
Nursing Intervention
At the end of 3 days
Independent:
Subjective:
Atong abril 13 imbes
duty the patient will be
padulong ko pamista,
able to:
Establish Rapport
pagbangon nako
nalipong ko as
Partiqcipate in
Monitor Vital
verbalized
activities that
Signs
decreases blood
pressure
History Taking

Objective:
>Distended Jugular vein
noted
> pallor noted on lower
extremities and nail beds
>bluish discoloration on
buccal area and tongue
>cold clammy skin on
lower extremities
>decreased capillary
refill
>weak pulses on lower
extremities.
>crackles sounds noted
on right lower lobe.
>cough noted
>BP: 180/90mmHg
>muscle atrophy on both
lower extremities noted

Rationale

Evaluation
At the end of 3 days
nursing intervention:

To gain patients trust

To obtain baseline data

To determine
contributing factors

Assess patients
condition

To determine present
condition

Monitor BP, PR
frequently

To note response to
activity

Provide
information on test
procedures

To gain patients
participation & decrease
anxiety level

Explain dietary
restrictions like
sodium restriction
and low-fat, low
cholesterol intake.

To inform patient of
contributing factors

Encourage rest &

reposition client
q2h

To decrease stress and

promote venous return

Goal is partially met

since the client was
able to participate in
the activities given
but the blood
pressure was not
controlled.

 Encourage
relaxation
techniques

To alleviate anxiety &

stress

Encourage to
increase activity
level as tolerated

To maintain functional
ability

Teach home BP
reading &
monitoring.

To detect change in VS
& seek timely
intervention

Nursing Diagnosis 2: Risk for fall related to incorrect use of assistive device (crutches) and visual alteration
Cues/Evidences
Subjective:
naaksidente man gud
ko mao nadaot akong
pikas mata ug halaphalap napod akong wala
nga mata as verbalized.

Outcome Criteria
At the end of 4 hours
duty the patient will be
able to:
Verbalize at least
three safety
precaution.
Be free of fall or
injury.

Nursing Intervention
Independent:
Identify factors that
affect safety needs.

Assess the patients

ability to ambulate
safely with or without
assistive devices.

Rationale
To know the
intervention that will be
established.
It is helpful to determine
the clients functional
abilities to plan for ways
of improving the
problem areas

Thoroughly orient the

patient to
environment.

For the client to

familiarize the
surroundings.

Assess vision and

provide adequate
lighting to clearly see
the pathway.

To provide well-lighted
environment and avoid
the occurrence of injury.

Ask the significant

others to look after
the client every now
and then.

To ensure clients safety.

Instruct the patient to

call for assistance
when moving.

To prevent the patient

from falling on bed.

Objective:
81 year old
Right eye non-functional
noted
Cloudiness noted at the
left cornea
Decreased strength in
both lower extremities
Weak in appearance
Occasional dizziness
noted
Incorrect use of crutches
noted

Evaluation
At the end of 4 hours
nursing intervention:

Goal is met since

the client was
able to verbalize
three safety
precaution.
Goal is met since
the client was
free from fall or
injury.

 Encourage to use
hand rails when in the
bathroom if available.

To reduce the risk of

falling

Teach appropriate use

of assistive devices
for crutches.

For the clients support.

Ensure that the patient To prevent from

wears proper shoes
slipping.

Nursing Diagnosis 3: Knowledge deficit related to lack of information about the disease process and self-care.
Cues/Evidences
Subjective:

Outcome Criteria
At the end of 4 hours
duty the patient will be
Giresitaan ko ug tambal able to:
para sa high blood pero
akong giundangan
Verbalize
pagkahuman sa us aka
understanding of
bulan kay wala koy
condition, disease
gibati nga naayo ko as
process and
verbalized.
treatment by
naming atleast 3
tig-inum ko ug kape
lifestyle changes.
matag kaon nako,
makahurot ko ug 3 ka
tasang kape sa sulod sa
us aka adlaw as
verbalized
kagahapon sa gabie ang
among sud-an kay
karneng baboy dayun
karung pamahaw
karneng baboy gihapon
as verbalized
nagainom ko ug tambal
nga gisagulan ug kulafu
ug 108 ka klase nga
kahoy nga gigutad
gutad, makainom ko ani
ug tungang baso matag
sunod na adlaw, as

Nursing Intervention
Independent:

Rationale

Evaluation
At the end of 4 hours
nursing intervention:

Assess readiness and blocks

to learning. Include the
family or significant others
in the learning process.

Misconceptions and denial of

the diagnosis because of long- Goal is met since the
standing feelings of wellclient was able to
being may interfere with
identify atleast 3
patient and SO willingness to
lifestyle changes
learn about disease,
meaning he atleast
progression, and prognosis. If
clearly understood his
patient does not accept the
condition and the
reality of a life-threatening
treatment needed.
condition requiring continuing
treatment, lifestyle and
behavioral changes will not be
initiated or sustained.

Define and state the limits of

desired BP. Explain
hypertension and its effects
on the heart, blood vessels,
kidneys, and brain.

Provides basis for

understanding elevations of
BP, and clarifies frequently
used medical terminology.
Understanding that high BP
can exist without symptoms is
central to enabling patient to
continue treatment, even
when feeling well.

Avoid saying normal BP,

and use the term wellcontrolled to describe
patients BP within desired
limits.

Because treatment for

hypertension is lifelong,
conveying the idea of
control helps patient
understand the need for

verbalized.

Objective:
>BP: 180/90 mmHg
>BMI: 25.7
(overweight)
>more than 2 oz intake
of alcohol every other
day noted

continued treatment and

medication.
Assist patient in identifying
modifiable risk factors
(overweight; diet high in
sodium, saturated fats, and
cholesterol; smoking;
alcohol intake of more than
2 oz per day on a regular
basis.).

These risk factors have been

shown to contribute to
hypertension and
cardiovascular and renal
disease.

Problem-solve with patient

to identify ways in which
appropriate lifestyle
changes can be made to
reduce modifiable risk
factors.

Changing comfortable or
usual behavior patterns can
be very difficult and stressful.
Support, guidance, and
empathy can enhance
patients success in
accomplishing these tasks.

Discuss importance of
avoiding smoking.

Nicotine increases
catecholamine discharge,
resulting in increased heart
rate, BP, vasoconstriction, and
myocardial workload, and
reduces tissue oxygenation.

Reinforce the importance of

adhering to treatment
regimen and keeping
follow-up appointments.

Lack of cooperation is a
common reason for failure of
antihypertensive therapy.
Therefore, ongoing evaluation
for patient cooperation is
critical to successful

treatment. Compliance
usually improves when
patient understands causative
factors and consequences of
inadequate intervention and
health maintenance.
Instruct and demonstrate
technique of BP selfmonitoring. Evaluate
patients hearing, visual
acuity, manual dexterity,
and coordination.

Monitoring BP at home is
reassuring to patient because
it provides visual and positive
reinforcement for efforts in
following the medical
regimen and promotes early
detection of deleterious
changes.

Rise slowly from a lying to Measures reduce severity of

standing position, sitting for orthostatic hypotension.
a few minutes before
standing. Sleep with the
head slightly elevated.
Suggest frequent position
Decreases peripheral venous
changes, leg exercises when pooling that may be
lying down.
potentiated by prolonged
sitting/standing.
Explain rationale for
prescribed dietary regimen
(usually a diet low in
sodium, saturated fat, and
cholesterol).

Excess saturated fats,

cholesterol, sodium, alcohol,
and calories have been
defined as nutritional risks in
hypertension. A diet low in fat
and high in polyunsaturated

fat reduces BP, possibly

through prostaglandin balance
in both normotensive and
hypertensive people.
Help patient identify
sources of sodium intake
(table salt, salty snacks,
processed meats and
cheeses, sauces, canned
soups and vegetables,
baking soda, baking
powder, monosodium
glutamate). Stress the
importance of reading
ingredient labels of foods
and OTC drugs.

Two years on a moderate lowsalt diet may be sufficient to

control mild hypertension or
reduce the amount of
medication required.

Provide information
regarding community
resources, and support
patient in making lifestyle
changes. Initiate referrals as
indicated.

Community resources such as

the American Heart
Association, coronary
clubs, stop smoking clinics,
alcohol (drug) rehabilitation,
weight loss programs, stress
management classes, and
counseling services may be
helpful in patients efforts to
initiate and maintain lifestyle
changes.