ACTUAL PROBLEM

Problem # 1

ASSESSMENT DIAGNOSIS SIGNIFICANT BASIS PLANNING INTERVENTION RATIONALE EVALUATION

S: “usahay malipong ug Decreased Stimulation of vasomotor Short-Term Assess underlying  To determine Short-Term
maglabad gamay akong Cardiac center (loc in medulla) send Objective: condition what triggers the Objective:
tan-kugo if musaka Output impulses to CNS elevated BP
akong BP”, as verbalized related to After 8 hours of  Changes in BP After 8 hours of
by the patient. elevated Acethylcoline released by nursing Monitor blood may indicates nursing
blood prosta preganglionic neurons intervention the pressure for every changes in intervention the
pressure as clients blood 30 minutes patients status client has no
O: manifested by Preganglionic fiber releases pressure will requiring prompt elevation in his
 Conscious and occipital decreased to medical attention blood pressure
coherent headache Norepinephrine(constriction acceptable limits Observe skin color,  Peripheral Goal was met
 Able to perform of blood vessel thereby temperature, vasoconstriction
ADL’s increasing blood pressure capillary refill, and may result in
 Dizziness noted diaphoresis pale,cool,clammy
occasionally adrenal medulla secrets skin,with
 With initial vital signs epinephrine prolonged
of capillary refill
BP:140/100mmHg increased blood pressure time
PR: 103 bpm causing it to increase blood Long-Term Do frequent  It may decrease Long-Term
RR: 18 bpm supply in the brain causing Objective: positioning to the peripheral Objective:
Temp: 36.9°c occipital headache patient venous pooling
After 3-5 days of that may After 3-5 days of
nursing potentiated by nursing
interventions the vasodilators and intervention the
client will prolong sitting or patient maintains
maintain normal standing a stable blood
and stable blood Administer  Inhibits influx of pressure Goal
pressure prescribed drugs Calcium ion was met.
(anti-hypertensive) across cell
as maintenance membrane to
produce
relaxation of
coronary smooth
 muscle
Encouraged pt to  This are cardiac
decrease intakes of stimulant and
caffeine, cola ,and may adversely
chocolate affect cardiac
function
Emphasize the  Hypertension is
concept of life time illness,
controlling controlling it is
hypertension rather the best way to
than curing it. stop it from
reoccurring

Encouraged patient  Salty and fatty

to maintain low salt food are one of
low fat diet the common
cause of
hypertension

Problem # 2

ASSESSMENT DIAGNOSIS SIGNIFICANT BASIS PLANNING INTERVENTION RATIONALE EVALUATION

S: “usahay malipong ug Ineffective Tissue Stimulation of vasomotor Short-Term  Monitor VS at least  To monitor Short-Term
maglabad gamay akong Perfusion: center (loc in medulla) send Objective: q 1-2 hrs and prn. baseline data. Objective:
tan-kugo if musaka Cardiopulmonary, impulses to CNS
akong BP”, as verbalized Gastrointestinal After 8 hrs of  Encourage patient  Caffeine is a After 8 hrs of
by the patient. and Peripheral r/t Acethylcoline released by nursing to decrease intake cardiac nursing
hypertension and prosta preganglionic interventions, of caffeine, cola stimulant and interventions,
decreased cardiac neurons blood pressure and chocolates. may adversely blood pressure
O: output as will be within set affect cardiac maintained
 Tachycardia manifested by Preganglionic fiber releases parameters for  Administer function. within set
 Rales blurred vision and the client. vasoactive drugs  These frugs have parameters for
 Cool, clammy skin increased blood Norepinephrine(constriction and titrate as rapid action and the client.
 Noted usage of pressure of blood vessel thereby ordered to may decrease Goal was met.
 correctional glasses, increasing blood pressure maintain pressures the blood
blurry vision at set parameters pressure too
occasionally persist adrenal medulla secrets for patient. rapidly, resulting
 Increased blood epinephrine in complications.
pressure
 With initial vital signs vasoconstriction of Long-Term  May indicate
of bloodvessels causing it to Objective:  Observe for cyanide toxicity Long-Term
BP:140/100mmHg release renin complaints of from increasing Objective:
PR: 103 bpm After 3-5 days of blurred vision, intracranial
RR: 18 bpm angiotensin I conver to nursing tinnitus or pressure. After 3-5 days of
Temp: 36.9°c angiotensin interventions, confusion.  I&O will give an nursing
II(vasoconstriction) the client will indication of interventions,
have an fluic balance or the client had an
secretion of aldosterone adequate tissue  Monitor I&O imbalance, thus adequate tissue
causing sodium and water to perfusion to his status. allowing for perfusion to his
retained witch leads to body systems. changes in body systems.
increase intravascular treatment Goal was met.
volume regimen when
required.
poor circulation

less oxygen supply in the  Monitor for  May indicate

brain & Heart sudden onset of dissecting aortic
chest pain. aneurysm.
leads to blurry vision,
Compensatory Increased of  Monitor ECG for  Decreased
Heart rate changes in rate, perfusion may
rhythm, result in
dysrhythmias and dysrhythmias
conduction caused by
defects. decrease in
oxygen.
 Observe  Bedrest
extremities for promotes
swelling, venous statis
erythema, which can
tenderness and increase the risk
pain. Observe for of
 decreased thromboembolu
peripheral pulses, s formation. If
pallor, coldness treatment is too
and cyanosis. rapid and
aggressive in
decreasing the
blood pressire,
tissue perfusion
will be impaired
and ischemia
can result.
 Instruct client in  Promotes
signs/symptoms to knowledge and
report to physician compliance with
such as headache treatment.
upon rising, Promotes
increased blood prompt
pressure, chest detection and
pain, shortness of facilitates
breath, increased prompt
heart rate, visual intervention.
changes, edema,
muscle cramps and
nausea and
vomiting.
 POTENTIAL PROBLEM

Problem # 3

ASSESSMENT DIAGNOSIS SIGNIFICANT BASIS PLANNING INTERVENTION RATIONALE EVALUATION

S: “usahay malipong ug Ineffective Tissue Stimulation of vasomotor Short-Term  Assess for general  To determine Short-Term
maglabad gamay akong Perfusion: center (loc in medulla) send Objective: status what causes the Objective:
tan-kugo if musaka akong Cardiopulmonary, impulses to CNS dizziness and
BP”, as verbalized by the Gastrointestinal After 8 hrs of what health After 8 hrs of
patient. and Peripheral r/t Acethylcoline released by nursing teaching to nursing
hypertension and prosta preganglionic interventions, provide interventions,
decreased cardiac neurons blood pressure  Assess level of  To monitor blood pressure
O: output as will be within consciousness patient’s maintained
 Conscious and manifested by Preganglionic fiber releases set parameters changes of within set
coherent blurred vision and for the client. sensorium; parameters for
 Dizziness noted increased blood Norepinephrine(constriction Increased BP the client.
 Able to do ADL’s pressure of blood vessel thereby may indicates Goal was met.
with assistance increasing blood pressure increased in
 Initial v/s of cerebrovascular
BP:140/100mmHg adrenal medulla secrets pressure
PR: 103 bpm epinephrine
RR: 18 bpm  Monitor vital  To monitor
Temp: 36.9°c vasoconstriction of Long-Term signs especially patients status
bloodvessels causing it to Objective: blood pressure increase in BP Long-Term
release renin indicates Objective:
After 3-5 days of increased in
angiotensin I conver to nursing cerebrovascular After 3-5 days of
angiotensin interventions, pressure nursing
II(vasoconstriction) the client will  Monitor for the  To determine if interventions
have an side effect of this drugs has the patient is
secretion of aldosterone adequate tissue drugs given something to do now free from
causing sodium and water to perfusion to his with the dizziness and
retained witch leads to body systems. patients able to do ADL’s
increase intravascular dizziness without any fear
volume from being
 Limit activities  This may help injured.
poor circulation and maintain alleviate
 quite, non dizziness by
less oxygen supply in the stressful letting the client
brain & Heart environment have peaceful
rest
leads to blurry vision,  Position patient in  Trendelenburg
Compensatory Increased of a trendelenburg position
Heart rate position facilitates easy
back flow of
blood from the
heart
 Provide safety by  To prevent the
raising the side patient from
rails falling down in
the bed
 Encouraged to  Sudden
avoid sudden movement
movement aggravate the
dizziness
 Advised SO to  to have
always somebody to
accompany the help her
patient whenever the
dizziness will
occur