NURSING ACTIONS & RATIONALE OF

CUES NURSING SCIENTIFIC BASIS GOAL & OUTCOME NURSING NURSING ORDERS EVALUATION
DIAGNOSIS CRITERIA ORDERS
Objective:  Risk for Atrial  High blood pressure  After 8 hours of INDEPENDENT  Provides basis for After 8 hours of
Hypertension Fibrillation (HBP or hypertension) nursing  Define and understanding nursing
HR: 120bpm due to is when your blood interventions, state the limits elevations of BP, interventions, the
patient was able
Imbalanced pressure, the force of the patient will of BP, and its and clarifies
to verbalize
Height: 5’9” Nutrition: your blood pushing verbalize effect on the misconceptions understanding of
Weight: 220 lb More Than against the walls of your understanding heart, blood and also the disease
BMI: 32.5 kg/m2 Body blood vessels, is of the disease vessels, kidney, understanding that process and
Requirements consistently too high. process and and brain. high BP can exist treatment
 Hypertension is the treatment without symptom regimen.
term used to describe regimen. or even when
high blood pressure.  Patient will feeling well.
Hypertension is identify  Assist the  These risk factors
repeatedly elevated correlation patient in have been shown
between
blood pressure identifying the to contribute the
hypertension
exceeding 140 over 90 and obesity. modifiable risk hypertension.
mmHg. It is categorized factors like diet
as primary or  Patient will high in sodium,
essential (approximatel demonstrate saturated fats
change in
y 90% of all cases) and cholesterol.
eating patterns
or secondary, which (e.g., food
occurs as a result of an choices,  Reinforce the  Lack of
identifiable, sometimes quantity) to importance of cooperation is
correctable pathological attain desirable adhering the common reason
condition, such as renal body weight treatment for failure of
disease or primary with optimal
regimen and antihypertensive
maintenance of
aldosteronism. keeping follow therapy.
health.
 The American College up appointment.
of Cardiology and  Patient will
initiate/maintain
American Heart  Suggest  Decrease
individually
Association published frequent peripheral venous
appropriate
new guidelines (as of exercise position pooling that may
2018) and ways to program. changes, leg be potentiated by
categorize blood exercises when vasodilators and
pressure.  lying down. prolong sitting or
 standing.
- Normal: Less than  Help patient
120/80 mmHg;  identify sources  Two years on
- Elevated: Systolic of sodium moderate low salt
between 120-129 and intake. diet may be
diastolic less than 80;  sufficient to control
- Stage 1: Systolic  Encourage mild hypertension.
between 130-139 and patient to  Caffeine is a
diastolic 80-89 decrease or cardiac stimulant
eliminate and may be
- Stage 2: Systolic 140 or
caffeine like adversely affect
higher and diastolic at
tea, coffee, cola cardiac function.
90 or higher. 
and chocolate.
- Hypertensive Crisis:
 Stress
Higher than 180 for
importance of  Alternating rest
systolic and diastolic
accomplishing and activity
higher than 120. 
daily rest increases
periods. tolerance to
activity
 Determine progression.
patient’s desire  Motivation for
to lose weight. weight reduction is
internal. The
individual must
want to lose
weight, or the
 Establish a program most
realistic weight likely will not
reduction plan succeed.
with the patient  Reducing caloric
such as 1 lb
weight loss per intake by 500
wk. calories daily
theoretically yields
a weight loss of 1
lb per wk. Slow
reduction in weight
is therefore
 indicative of fat
loss with muscle
sparing
and generally
COLLABORATIVE reflects a change
in eating habits.
 Provide
information
regarding  Community
community resources like
resources, and health centers
support patients programs and
in making checkups are
lifestyle helpful in
changes. controlling
hypertension.
 DISCHARGE PLAN

Patient’s Name: F. Hospital No: N/A

Age: 67 years old Room No: N/A
Impression/Diagnosis: Hypertension risk for atrial fibrillation due to Physician: N/A
Imbalanced nutrition: More than Body Requirement
Nurse’s Name & Signature: SHANIA LAINE CABUCOS

PATIENT’S OUTCOME CRITERIA NURSING ORDER

Expected behavior of the patient when discharged. Nurse’s action to help patient do expected behavior
when discharged.
ASSESSING
- Educate patient to maintain BP within
- Assess vital signs: Normal
individually acceptable range

- Stable cardiac rhythm and rate within patient’s - Advice patient to avoid unhealthy diets and
normal range ways that can affect his health

- Balanced weight - Encourage patient to maintain balance diet

PLANNING

- Suggest frequent position changes, leg

- Patient will initiate/maintain individually
appropriate exercise program. exercises and when lying down.
- Patient is able to demonstrate what health care - Make sure that the patient initiate
provider instructed cooperation during demonstration

IMPLEMENTING
- Advice patient to continue medications as
M- Follow medication as prescribe prescribed
- Let patient exercise to maintain health,
E- Daily exercise balance weight and to eliminate stress
T- Continue treatment - Explain the importance of following and
continuing the treatment process
H- Able demonstrate the importance of cleanliness or - Educate proper hygiene
proper hygiene and its effect in daily routine or lifestyle

O- Instruct to follow checkup if any

- To maintain health protocols
D- Will demonstrate change in eating patterns (e.g.,
food choices, quantity) to attain desirable body weight - Educate patient about his proper diet
with optimal maintenance of health.

EVALUATING
- Goal met

Consideration:
M Medication
E Exercise/Environment
T Treatment
H Hygiene
O Out-patient referrals/ Observable sign and
symptoms
D Diet