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  • Assessment Diagnosis Rationale Planning Implementation Rationale Evaluation Subjective Data Short-Term: Independent Short-Term

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    Diane Krystel G. Morales
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    The document summarizes a nursing assessment, diagnosis, plan, and evaluation for a patient presenting with disturbed sensory perception as evidenced by high blood pressure, rapid breathing and heart rate, numbness, and dizziness. The nursing diagnosis was determined to be disturbed sensory perception due to hypertension. The short-term plan was to monitor vital signs and symptoms, educate the patient, and encourage relaxation techniques. After 3 hours the patient's condition had stabilized. The long-term plan included increasing activity tolerance and participation in heart-healthy activities. After 8 hours the patient was able to meet these long-term goals.

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    NCP 2

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    The document summarizes a nursing assessment, diagnosis, plan, and evaluation for a patient presenting with disturbed sensory perception as evidenced by high blood pressure, rapid breathing and heart rate, numbness, and dizziness. The nursing diagnosis was determined to be disturbed sensory perception due to hypertension. The short-term plan was to monitor vital signs and symptoms, educate the patient, and encourage relaxation techniques. After 3 hours the patient's condition had stabilized. The long-term plan included increasing activity tolerance and participation in heart-healthy activities. After 8 hours the patient was able to meet these long-term goals.

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    © All Rights Reserved
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    6 views2 pages

    Assessment Diagnosis Rationale Planning Implementation Rationale Evaluation Subjective Data Short-Term: Independent Short-Term

    Uploaded by

    Diane Krystel G. Morales
    The document summarizes a nursing assessment, diagnosis, plan, and evaluation for a patient presenting with disturbed sensory perception as evidenced by high blood pressure, rapid breathing and heart rate, numbness, and dizziness. The nursing diagnosis was determined to be disturbed sensory perception due to hypertension. The short-term plan was to monitor vital signs and symptoms, educate the patient, and encourage relaxation techniques. After 3 hours the patient's condition had stabilized. The long-term plan included increasing activity tolerance and participation in heart-healthy activities. After 8 hours the patient was able to meet these long-term goals.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    John Victor B. Felix & Diane Krystel G.

    Morales

    Assessment Diagnosis Rationale Planning Implementation Rationale Evaluation

    Subjective Data Disturbed sensory Disturbed sensory Short-term: Independent Short-term:


    “Namamanhid sa may perception as evidenced perception is the change After 3 hours of nursing ● Monitor vital signs This provides a baseline After 3 hours of nursing
    talinga tapos kabanga by BP of 190/100, RR in the amount of interventions the patient every 30 minutes. for comparison to follow interventions the patient
    kang hawak ki” as 30bpm, numbness and patterning of incoming will be able to: care and evaluate was able to:
    verbalized by the patient. dizziness. stimuli accompanied by a . response to intervention.
    diminished, exaggerated, ● Display ● Display
    Subjective Data distorted, or impaired hemodynamic ● Asses and monitor May indicate evolving; hemodynamic
    response to such stimuli. stability e,g blood for clients reports of can also accompany stability e,g blood
    ● Body weakness In our patient, numbness, pressure of chest pain. congestive heart failure. pressure of
    noted weakness, dizziness, and 150/90, pulse rate 150/90, pulse rate
    ● (+) Impaired impaired communication of 100bpm and ● Position the patient By maintaining alignment of 100bpm and
    communication were observed due to RR of 20 bpm. in her comfortable and for preventing bed RR of 20 bpm.
    ● (+) Dizziness hypertension and evident ● Verbalize position. sores (pressure ulcers), ● Verbalized
    with blood pressure of knowledge of the foot drop, and knowledge of the
    PR - 110 190/100. disease process contractures. disease process
    RR - 30 and treatment and treatment
    BP - 190/100 plan. ● Encourage To decrease the stress plan.
    Temp - 37.1°C relaxation effects on the mind and
    O2 Sat - 92% techniques such as body of the patient.
    Long-term: deep breathing. Long-term:
    After 8 hours of nursing After 8 hours of nursing
    interventions the patient ● Provide a calm To reduce anxiety and interventions the patient
    will be able to: environment. muscle tension. was able to:

    ● Demonstrate an ● Encourage the It allows the body's blood ● Demonstrate an


    increase in activity patient to have an pressure to regulate itself. increase in activity
    tolerance. adequate rest. tolerance.
    ● Participate in ● Participate in
    activities that ● Monitor and Regulation ensures the activities that
    reduce the regulate IVF Q30 correct amount of fluid reduce the
    workload of the mins. drips from a bag down workload of the
    heart. the IV into the vein at the heart.
    correct rate.

    ● Provide diet To control your heart


    restrictions for low failure symptoms and
    salt, low fat diets. prevent future heart
    problems.
    John Victor B. Felix & Diane Krystel G. Morales

    Dependent
    ● Administer Adherence to treatment is
    medication as important for controlling
    prescribed by the chronic conditions,
    physician. treating temporary
    conditions, and overall
    long-term health and
    well-being.

    ● Provide fluids and To minimize dehydration


    electrolytes as and dysrhythmias.
    prescribed by the
    physician.

    Collaborative
    ● Collaborate with They provide medical
    nutritionists for the nutrition therapy and
    appropriate diet of assist in coaching
    the patient. patients about proper
    nutrition.

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