ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Decreased Cardiac Goals:  Monitor BP every 1-2 o Changes in BP may Goals partially met:
“madalas ako ng Output r/t After 5 days of hours, or every 5 indicate changes
mahilo”, as hypertension as nursing minutes during active in patient status After 5 days of nursing
verbalized by the manifested by interventions, the titration of vasoactive requiring prompt interventions, the client
patient. decreased stroke client will maintain drugs. attention. maintained an adequate
volume. adequate cardiac  Monitor ECG for o Decrease in cardiac output and
output and cardiac dysrrhythmias, cardiac output cardiac index.
Objective: index. conduction defects may result in
 lethargic and for heart rate. changes in cardiac After 6 hrs of nursing
 decreased perfusion causing interventions, the client
cardiac output Objectives: dysrhythmias. had no elevation in blood
 decreased After 8 hrs of  Suggest frequent o It may decreases pressure above normal
stroke volume nursing position changes. peripheral venous limits but not maintain
 increased interventions, the pooling that may blood pressure within
peripheral client will: be potentiated by acceptable limits.
vascular  Demonstrate the vasodilators and
resistance planned prolonged sitting
interventions on or standing.
VS taken as follows: lowering blood  Encourage patient to o Caffeine is a
PR: 91bpm pressure. decrease intake of cardiac stimulant
BP: 180/100 mmHg  Participate in caffeine, cola and and may adversely
treatment chocolates. affect cardiac
regimen (e.g. diet function.
restriction of  Observe skin color, o Peripheral
sodium, and temperature, capillary vasoconstriction
frequent position refill time and may result in pale,
changes) diaphoresis. cool, clammy skin,
 Have no elevation with prolonged
in blood pressure capillary refill time
above normal due to cardiac
limits dysfunction and
 Will maintain decreased cardiac
blood pressure output.
within acceptable 6. Auscultate heart tones. o Hypertensive
limits. patients often
have S4 gallops
caused by atrial
7. Administer medicines hypertrophy.
as prescribed by the o to promote
physician. wellness.
8. Instruct client & family
on fluid and diet
requirements and o Restrictions can
restrictions of sodium. assist with
decrease in fluid
9. Instruct client and retention and
family on medications, hypertension,
side effects, thereby improving
contraindications and cardiac output.
signs to report.  9. Promotes
knowledge and
compliance with
drug regimen.