Nursing Nursing Interventions and

Cues Background Knowledge Goal and Objectives Evaluation

Diagnosis Rationale
Decreased cardiac output is an NOC: Circulation Status NIC: Hemodynamic Regulation
Subjective: Risk for Decreased often-serious medical condition
 Patient M.M Cardiac Output that occurs when the heart does Goal:
verbalized, related to not pump enough blood to meet  After 3 days of nursing
“Tuwing increased vascular the needs of the body. It can be interventions, the client will
inaatake ako ng resistance as caused by multiple factors, be able to maintain blood
highblood, grabe evidenced by some of which include heart pressure within individually
yung hilo na verbalization of disease, congenital heart acceptable range.
nararamdaman dizziness and BP defects, and low blood
ko tapos masakit of 130/90 pressure. (PrepScholar, 2017) Objectives:
rin yung batok
ko.” After 8 hours of nursing The student nurse will: After 8 hours of nursing
interventions, the client will be able interventions,
Objective: to:
 BP: 130/90
1. Demonstrate stable blood 1. Monitor and record blood 1. The patient was able to
pressure within normal pressure in both arms and demonstrate stable
range thighs. Take 3 readings, 3- 5 blood pressure within
minutes apart while client is at the accepted normal
rest, then sitting, and then range.
standing for initial evaluation.
Use correct cuff size and
accurate technique, and take
note of elevations in systolic, as
well as diastolic readings to
provide a more complete
picture of the vascular
involvement, and scope of the
problem.

 Auscultate heart tones and

breath sounds to identify
presence of crackles, and
wheezes which may
indicate pulmonary
congestion secondary to
developing of chronic
heart failure.

 Administer and monitor

response to medications
that control BP to prevent
adverse effects and
worsening of condition.
2. Participate in activities that
reduce BP/ cardiac
workload
3. Engage in activities that will
prevent stress ( stress
2. Implement dietary sodium, fat, 2. The patient was able to
and cholesterol restriction as participate In activities
indicated to help manage fluid that help reduce BP/
retention and with associated cardiac workload.
hypertensive response,
decrease myocardial
workload.
 Provide comfort measures,
such as back and neck
massage or elevation of the
head to decrease
discomfort and reduce
sympathetic stimulation.
 Encourage patient to
engage in physical activity
to help control blood
pressure and manage
weight.
3. The patient was able to
3. Maintain activity restrictions; engage in activities
schedule of uninterrupted rest; that prevent stress.
 management, balanced
activities, and rest plan)
and assist patient with self- care
activities as needed to lessen
physical stress and tension
that affect blood pressure and
the course of hypertension

 Instruct relaxation
techniques, guided imagery
and distractions to reduce .
stressful stimuli by
producing calming effect,
thereby reducing blood
pressure.
This condition is defined as a NOC: Endurance NIC: Energy Management
Subjective Activity state in which a person has
 Presently, as Intolerance related insufficient physiological or Goal:

verbalized by to Hypertension as psychological energy to After 3 days of nursing

the patient, evidenced by endure or complete necessary interventions, the patient will be
report of dizziness or desired daily activities. able to maintain adequate energy
“Tuwing
(Medical Dictionary, 2012) and verbalize improvement of health
inaatake ako
evidence by increase tolerance in
ng highblood,
performing activities of daily living.
grabe yung
hilo na
nararamdaman Objectives:
 ko kaya hindi After 8 hours of nursing The nurse will: After 8 hours of nursing
ko rin interventions, the client will be able intervention the patient was

nagagawa yung to: able to:

mga dapat
1. Understand and limits herself in 1. Assess patient’s 1. Determine the factors that
kong gawin, at
doing loads of work and Report physiological status for facilitates her condition
hindi ko rin
increase in energy levels. deficits resulting in and now knows how limits
magawa
fatigue within the herself in the activities that
magoffice. context of age and can worsen her condition.
Tapos masakit development. This
rin yung batok provides baseline
ko.” information for
formulating nursing
goals during goal
Objective:
setting.
 BP: 130/90
mmHg
 Encourage verbalization of
feelings about limitations.
This helps the patient to
cope. Acknowledgment
that living with activity
intolerance is both
physically and emotionally
difficult.
2. Improve her eating habits and 2. Educate patient about 2. Identify foods that do not
gives importance in foods that play the foods that play required much processing
important role in conserving energy. important roles in and foods eat the most
energy conservation. efficient foods for energy
Monitor nutritional conservation
intake to ensure .
adequate energy
resources. Adequate
energy reserves are
needed during
activity.

3. Maintain comfort throughout 3. Refrain from 3. Maintain comfort and

the intervention. performing conserve energy
nonessential activities throughout the activity.
or procedures. Patient
with limited activity
tolerance need to
prioritize important
tasks first.
  Assist with ADLs while
avoiding patient
dependency. Carefully
balance provision of
assistance; facilitating
progressive endurance will
ultimately enhance the
patient’s activity tolerance
and self-esteem.

4. Reports being energize after the 4. Assist the patient to 4. Report increased in energy
provided activity. limit work and have a levels evidenced by
sufficient time of sleep moving around and
by providing activity engaging in the
that promotes restful interventions performed.
sleep. Sleep
deprivation and
difficulties during
sleep can affect the
activity level of the
patient – these needs
to be addressed
before successful
activity progression
 can be achieved.

 Identify activities she can

independently perform as
tolerated to help in
increasing the tolerance
for the activity.

 Assist the patient to

understand energy
conservation principles
such as:
 Sitting to do tasks
 Frequent position
changes
 Pushing rather than
pulling
 Sliding rather than
lifting
 Working at an even
pace
 Placing frequently
used items within easy
reach
  Resting for at least 1
hour after meals before
starting a new activity
 Using wheeled carts
for laundry, shopping,
and cleaning needs
 Organizing a work-
rest-work schedule
These techniques
reduce oxygen
consumption, allowing
a more prolonged
activity.
A condition where an NOC: Weight Control
Subjective: Imbalanced individual consumes nutrients
 Patient nutrition: More that exceeds his/ her metabolic Goal:

verbalized, than body needs. (NANDA- I, n.d.) After 3 days of nursing

“Noong na- requirement interventions, the patient will be

related to poor able demonstrate necessary
diagnose ako
dietary habits as measures and lifestyle modifications
ng
evidenced by BMI to lose weight.
hypertension,
that is >25 kg/ Objectives: After 8 hours of nursing
talagang
m^2 After 8 hours of nursing The nurse will: intervention the patient was
iniwasan ko na interventions, the client will be able able to:
lahat ng bawal to:
 sakin, pero 1. Verbalize willingness to 1. Assess client’s 1. Report inclination in
nahihirapan lose weight understanding of direct losing weight
talaga ako lalo relationship between
na pag masarap hypertension and obesity.
yung pagakin o Obesity is an added risk
kapag may with hypertension
mga handaan.” because of the
 Patient eats her disproportion between
meals for fixed aortic capacity and
thrice a day, increased cardiac output
with snacks in associated with
between. increased body mass.
Thus, reduction in
Objective: weight may reduce or
 Weight: 73 eliminate the need for
kilos drug therapy needed to
Height: 162. control BP.
56 cm
BMI: 27.4  Discuss necessity for
(overweight) decreased caloric intake
and limited intake of fats,
salt, and sugar, as
 indicated. Excessive salt
intake expands the
intravascular fluid
volume and may
damage kidneys, which
can further aggravate
hypertension.

 Determine client’s desire

to lose weight. The
client must be willing
and motivated to
undergo weight
reduction for the
program to succeed..

 Review usual daily

caloric intake and dietary
choices. To aid in
determining individual
need for adjustment and
teaching.
2. Enumerate necessary
dietary measures to 2. Establish client to
achieve weight reduction
 Instruct and assist client
2. Cite necessary steps
in managing her
maintain a diary of food nutrition to achieve
intake, including when weight reduction
and where easting takes
place and the
circumstances and
feelings around which
the food was eaten. This
provides a database for
both the adequacy of
nutrients eaten and the
relationship of emotion
to eating. Thus, helps in
focusing attention on
factors that the client
can control or change.
in appropriate food
selections such as
implementing a diet rich

3. Engage in weight loss
activities to facilitate
weight reduction
3. Instruct client to increase
in fruits, vegetables, and
low- fat dairy foods
referred to as the Dietary
Approaches to Stop
Hypertension (DASH)
diet. This will prevent
client’s sense of
deprivation and
enhance commitment to
achieve healthy goals.
The DASH diet, when
taken along with proper
exercise, may reduce or
eliminate the need for
drug therapy in the
early stages of
hypertension
. 3. Participate in
physical activities to
obtain weight loss
activity level to burn
calories to promote
weight loss.