Assessment

S: parang nararamdaman ko ung tibok ng puso ko as verbalized by the patient. O: hooked to O2 inhalation @ 1LPM on HGT monitoring on low cholesterol, low sugar diet c body malaise s chest pain s DOB c bradycardia (40 BPM) c weak and thready pulse c decreased peripheral pulses ambulatory c assistance afebrile (36.8 oC)

Nursing Diagnosis
Decreased Cardiac output r/t altered heart rate, rhythm, and reports of palpitations.

NURSING CARE PLAN Scientific Planning Interventions Explanation

Hypertensive cardiovascular disease also known as hypertensive heart disease occurs due to the complication of hypertension or high blood pressure. In this condition the workload of the heart is increased manifold and with time this causes the heart muscles to thicken. The heart continues pumping blood against this increased pressure and over a period of time the left ventricle of the heart enlarges and this in turn causes the blood pumped by heart to reduce. The patient will participate in activities that reduce the workload of the heart.
establish rapport place the client in a comfortable position monitor and record vital signs Assess skin color and temperature.

Rationale
to facilitate NPI. to prevent backaches or muscle aches. to note any significant changes that may be brought about by the disease Cold, clammy skin is secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output and desaturation. Pulses are weak with reduced cardiac output. Compromised regulatory mechanisms may result in fluid and sodium retention. Body weight is a more sensitive indicator of fluid or sodium retention than intake and output. Physical activity increases the demands placed on the heart; fatigue and exertional dyspnea are common problems with low cardiac output states. This indicates an imbalance between oxygen supply and demand. to maximize sleep periods and prevent

Evaluation
Patient participated in activities that reduced the workload of the heart.

Assess peripheral pulses. Assess fluid balance and weight gain.

Assess response to increased activity.

Assess for chest pain. promote adequate rest by decreasing stimuli, providing