ASSESSMENT

Subjective:
madalas ako mahilo ,
as verbalized by
the patient.
Objective:
-Vital Sign taken as
follow:
PR-87
RR-22
BP-180/100

DIAGNOSIS

PLANNING

. Decreased Cardiac
Output r/t malignant
hypertension as
manifested by
decreased stroke
volume

STG:
After 6 hrs of nursing
interventions, the
client will have no
elevation in
blood pressure above
normal limits and will
maintain
blood pressure within
acceptable limits.
LTG:
After 5 days of nursing
interventions, the
client will maintain
adequate cardiac
output and cardiac
index

INTERVENTION

-Monitor BP every 1-2

hours
-Suggest
frequent position
changes.
-Encourage patient to
decrease intake
of caffeine, cola and
chocolates
-observe skin color,
temperature, capillary
refill time and
diaphoresis
-administer medicines
as prescribed by
the physician

EVALUATION

STG:
After 6 hrs of nursing
interventions, the
client will have no
elevation in
blood pressure above
normal limits and will
maintain
blood pressure within
acceptable limits.
LTG:
After 5 days of nursing
interventions, the
client will maintain
adequate cardiac
output and cardiac
index. Goal was
met!!!