PHINMA University of Pangasinan

College of Health Sciences

NURSING CARE PLAN

Patient’s Initials: J. Rodes
Age & Gender: 35 years old female
Birthdate: December 26, 1986
Address: Arellano St. Pantal
Chief Complaint: Headache Name of the Student Nurse: Faith A. Calimlim
Admitting Diagnosis: Hypertension Stage II Level/Block/Group: Level 2/ 2BSN03/ GROUP 3
Clinical Instructor/s: Sir Michael Cayabyab
Date of Confinement:
Date: January 23 & 24, 2023

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE: High blood pressure usually Short term goal:  Assess underlying Short term goal:
develops over time. It can After 8 hours of condition  To determine what After 8 hours of
“Nagkaroon kami ng away sa happen because of nursing intervention, triggers the nursing intervention,
bahay at bigla nalang sumakit unhealthy lifestyle choices, the patient’s blood elevated blood the goal was MET.
yung ulo ko” as verbalized by the such as not getting enough pressure will decrease pressure The patient has no
patient. regular physical to acceptable limit.  Monitor blood elevation in his blood
activity. Certain health pressure every 30  Changes in blood pressure.
OBJECTIVE: conditions, such as minutes pressure may
diabetes and having indicate changes in
- Conscious and coherent obesity, can also increase patient’s status
- Afebrile the risk for developing high requiring prompt
- Initial VS taken as follow: blood pressure. Happiness, Long term goal: medical attention Long term goal:
anger, and anxiety increase After 3 days of nursing  Observe skin After 3 days of nursing
 BP: 180/100
blood pressure to differing intervention, the client color, intervention, the goal
 T: 36.0C  Peripheral
degrees and that emotional will maintain normal temperature, was MET. The patient
 PR: 87 vasoconstriction
effects may be greater in and stable blood capillary refill, and
 RR: 20 diaphoresis. may result in pale, has maintained a
 O2SAT: 98 individuals with more labile pressure cool, clammy skin, stable blood pressure.
blood pressure. Untreated with prolonged
hypertension increases the capillary refill time
level of stress-related
chemicals circulating in your  Do frequent
blood. Making matters positioning to the  It may decrease
worse, stress-related patient peripheral venous
chemicals increase blood pooling that may
pressure. potentiated by
 vasodilators and
prolong sitting or
standing

 Administer
prescribed anti-  Inhibits influx of Ca
hypertensive ion across cell
drugs membrane to
produce relaxation
of coronary smooth
muscle
 Encourage patient
 This are cardiac
to decrease
stimulant and may
intakes of
adversely affect
caffeine, cola, and
cardiac function
chocolates

NURSING DIAGNOSIS

Hypertension related to elevated  Emphasize the

blood pressure as manifested by concept of  Hypertension is life
occipital headache. controlling time illness,
hypertension controlling is the
rather than curing best way to stop it
it. from reoccurring

 Encourage patient
to maintain low  Salty and fatty food
salt low fat diet. are one of the
common cause of
hypertension