NCP PROPER

Priority Problem # 2: Ineffective Tissue Perfusion related to increased blood pressure.

Cues Explanation of the Problem Nursing Objectives Interventions Rationale Evaluation

S> “Madi High blood pressure (HBP)or LTO: After 72 hours of nursing Diagnostics: Monitor BP To check for possible Fully met if: the patient is
riknak,kasla hypertension means high intervention the patient will periodically, note presence of complications that the able to maintain a normal
maulaw pressure(tension) in the arteries. maintain a normal cardiac and quality of central and patient may have and to cardiac output and cardiac
ak,nagdagesen Arteries are vessels that carry output and cardiac index and peripheral pulses, auscultate monitor the progress in index and a BP= ranging from
daytoy barukong blood a BP= ranging from 120/90- heart tones and breath the effectivity of 120/90-130/90mmhg with no
ko ken nasakit” From the pumping heart to all 130/90mmhg with no more sounds, assess skin color, intervention being done. more heaviness of chest and
“nangato kanu ti the tissues and organs of the heaviness of chest and moisture, temperature and dizziness.
blood pressure ko” body. High blood pressure does dizziness. capillary refill.
not mean excessive emotional : note for signs of To determine if the
tension, edema. patient’s diuretic is not
O> Client is although emotional tension and STO: After 8 hours of nursing effective due to further
observed to be stress can temporarily increase interventions the patient will sodium and water
pale in color, skin is blood pressure. have no elevation in BP above retention.
cool and moist to Normal blood pressure is normal limits and will Partially met if: proper
touch, verbalized below 120/80; blood pressure maintain BP within : monitor response to To monitor the effectivity therapeutic technique such
heaviness of chest between 120/80and 139/89 is acceptable limits. medication for controlling of drugs being as relaxation techniques,
with chest pain, called "pre-hypertension", blood pressure. administered and to medications administered
easy fatigability. and a blood pressure of 140/90 determine the need for and proper DASH diet were
or above is considered high. After 10 mins. of health consulting the physician implemented and followed
Blood pressure An elevation of the systolic and/or teaching the client will be but patient is still
ranging from diastolic blood pressure able to understand and hypertensive.
170/90- increases the risk of adhere to the therapeutic Therapeutic: administer To control blood pressure
140/90mmhg as of developing heart interventions for medications: spironolactone and to maintain BP within
(09/18/17) @1pm (cardiac)disease, hypertension such as: having (diuretics), candesartan acceptable limits.
Pulse rate kidney(renal) disease, hardening a healthy diet, lessening (angiotensin II receptor
ranging from 73-87 of the arteries(atherosclerosis or intake of food high in sodium, antagonist), amlodipine Not met if: Client’s condition
bpm as of arteriosclerosis) cholesterol and saturated (calcium channel blocker). worsens and client have
(09/18/17) @8am ,eye damage ,and stroke(brain fats. : maintain activity To lessen stress factors elevation in BP above normal
damage).These complications restrictions and provide that may contribute in limits and did not maintain
Capillary refill of of hypertension are often comfort measures and elevating the BP of the BP within acceptable limits.
1-2 seconds referred to a send-organ damage relaxation techniques such as patient. With complications arisin
because damage to these organs
 Laboratory is the end result of chronic (long Deep Breathing Exercises
result: (09/15/17) duration) high blood pressure. (DBE).
=With low HDL
(39.05 mg/dl) and
calcium level

Educative: Instruct and Done to promote

implement to patient dietary
restrictions in sodium, fat and
cholesterol intake.
: encouraged to
report untoward signs such
as: pain, dizziness, nausea
and vomiting.
awareness of a healthy
diet for health condition
and help decrease the
blood pressure and further
complication that may
arise.