This nursing care plan addresses a 54-year-old patient with dizziness, neck pain, and high blood pressure. The plan includes assessments, nursing diagnoses, short and long-term goals, interventions, and an evaluation plan. Key points include:
1) The patient has been non-compliant taking blood pressure medications and only takes them during severe dizziness. Nurse will educate on importance of regular medication adherence.
2) The patient reports neck pain rated 8/10. Nurse will administer pain medications and non-pharmacological treatments, with a goal of reducing pain to 4/10 within 8 hours.
3) The patient has a family history of heart disease and is at
This nursing care plan addresses a 54-year-old patient with dizziness, neck pain, and high blood pressure. The plan includes assessments, nursing diagnoses, short and long-term goals, interventions, and an evaluation plan. Key points include:
1) The patient has been non-compliant taking blood pressure medications and only takes them during severe dizziness. Nurse will educate on importance of regular medication adherence.
2) The patient reports neck pain rated 8/10. Nurse will administer pain medications and non-pharmacological treatments, with a goal of reducing pain to 4/10 within 8 hours.
3) The patient has a family history of heart disease and is at
This nursing care plan addresses a 54-year-old patient with dizziness, neck pain, and high blood pressure. The plan includes assessments, nursing diagnoses, short and long-term goals, interventions, and an evaluation plan. Key points include:
1) The patient has been non-compliant taking blood pressure medications and only takes them during severe dizziness. Nurse will educate on importance of regular medication adherence.
2) The patient reports neck pain rated 8/10. Nurse will administer pain medications and non-pharmacological treatments, with a goal of reducing pain to 4/10 within 8 hours.
3) The patient has a family history of heart disease and is at
Chief complaint: Ineffective self-health Short-term goal: Assess patient's Assessment helps identify Goal: Mrs. Rosales will be Dizziness and nape management related to knowledge and knowledge gaps and compliant with her medication pain for the past 3 noncompliance with Within the next 24 understanding of misconceptions that can be regimen to manage hypertension days. medication regimen as hours, the patient will be hypertension and addressed through patient and prevent further complications. manifested by the patient able to verbalize medication regimen. education. (Ackley, B. J., & Subjective data: only taking Losartan understanding of the (Ackley, B. J., & Ladwig, Ladwig, G. B., 2018, p. 582) Outcome criteria: during severe dizziness importance of taking G. B., 2018, p. 582) Patient education is a Noncompliant with episodes and medication regularly as Provide patient crucial intervention to Mrs. Rosales takes her medication for 2 noncompliance with prescribed. education on the improve patient medication as prescribed every years medication for 2 years. importance of understanding and day. Family history of Long-term goal: medication adherence adherence to medication Mrs. Rosales reports cardiovascular and potential regimen. (Ackley, B. J., & experiencing fewer episodes of disease and Within the next 2 weeks, consequences of Ladwig, G. B., 2018, p. 582) dizziness and nape pain. diabetes the patient will be able noncompliance. (Ackley, Identifying potential barriers Mrs. Rosales' blood pressure is Only takes to demonstrate B. J., & Ladwig, G. B., and providing strategies consistently below 140/90 maintenance compliance with her 2018, p. 582) can help the patient mmHg. medication of medication regimen, as Identify potential overcome challenges to Expectations for goals being Losartan 50mg evidenced by taking her barriers to medication medication adherence. met: when she Losartan 50mg tablet adherence and provide (Ackley, B. J., & Ladwig, G. If Mrs. Rosales takes her experiences daily as prescribed. strategies to overcome B., 2018, p. 582) medication as prescribed every severe dizziness. these barriers. (Ackley, day, reports fewer episodes of B. J., & Ladwig, G. B., dizziness and nape pain, and Objective data: 2018, p. 582) her blood pressure is Acute pain related to Short-term goal: Assess patient's pain Assessment of pain consistently below 140/90 Blood pressure: nape pain as manifested intensity and intensity and characteristics mmHg, the goal will be met. 140/100 mmHg by the patient's complaint Within the next 8 hours, characteristics. (Ackley, helps identify the most Age: 54 years old of discomfort in the nape the patient will report a B. J., & Ladwig, G. B., appropriate pain If Mrs. Rosales takes her area. decrease in pain 2018, p. 708) management strategies. medication irregularly, intensity from 8/10 to Administer pain (Ackley, B. J., & Ladwig, G. continues to report frequent 4/10 on a pain scale. medications as B., 2018, p. 708) episodes of dizziness and nape prescribed. (Ackley, B. Pain medications can help pain, and her blood pressure Long-term goal: J., & Ladwig, G. B., alleviate pain and remains at or above 140/90 2018, p. 711) discomfort. (Ackley, B. J., & mmHg, the goal will be partially Within the next 2 days, Provide non- Ladwig, G. B., 2018, p. 711) met or unmet. the patient will report no pharmacological pain Non-pharmacological pain pain or discomfort in the relief measures such as relief measures can also Plan for continuation or nape area. cold or heat therapy. help manage pain and (Ackley, B. J., & Ladwig, improve patient comfort. revision: G. B., 2018, p. 712) (Ackley, B. J., & Ladwig, G. If the goal is met, the plan of care B., 2018, p. 712) will be continued as prescribed, Risk for cardiovascular Short-term goal: Assess patient's Assessment helps identify with regular monitoring of blood disease related to family understanding of knowledge gaps and pressure and medication history of the disease. Within the next 24 cardiovascular disease misconceptions that can be compliance. A follow-up hours, the patient will be and its risk factors. addressed through patient appointment will be scheduled in able to verbalize (Ackley, B. J., & Ladwig, education. (Ackley, B. J., & one month to assess progress and understanding of the G. B., 2018, p. 63) Ladwig, G. B., 2018, p. 63) adjust the plan of care if necessary. importance of lifestyle Provide patient Patient education is a modifications and education on modifiable crucial intervention to help If the goal is partially met or regular follow-up visits risk factors such as the patient identify and unmet, the plan of care will be to prevent the smoking, sedentary modify modifiable risk revised to address the barriers to development of lifestyle, and unhealthy medication compliance and blood cardiovascular disease. diet. (Ackley, B. J., & pressure control. The patient and Ladwig, G. B., 2018, p. family will be re-educated on the Long-term goal: 63) importance of medication Encourage patient to adherence and lifestyle Within the next 6 engage in regular modifications to manage months, the patient will exercise and maintain a hypertension. A referral to a demonstrate a decrease healthy diet. (Ackley, B. hypertension specialist may be in modifiable risk factors J., & Ladwig, G. B., considered. A follow-up such as smoking, 2018, p. 63) appointment will be scheduled in sedentary lifestyle, and two weeks to reassess progress unhealthy diet. and adjust the plan of care as Short-term goal: needed. Risk for stroke related to Monitor blood pressure Early identification of uncontrolled hypertension regularly: Assess blood changes in blood pressure as manifested by a blood pressure at least once can aid in prompt Rationale for revisions: Within the next 24 pressure reading of every shift, or as intervention to prevent a According to the American Heart hours, the patient's 140/100 mmHg. ordered by the stroke. (Doenges et al., Association (AHA), noncompliance blood pressure will be physician. (Doenges et 2021, p. 503) with medication regimens is a reduced to less than al., 2021, p. 503) common cause of uncontrolled 130/80 mmHg through Medications such as hypertension and subsequent medication management Administer angiotensin-converting complications. Lack of and lifestyle antihypertensive enzyme inhibitors, calcium understanding about the modifications. medications as channel blockers, and beta- importance of medication prescribed: blockers can lower blood adherence and lifestyle Long-term goal: pressure and reduce the modifications can contribute to risk of stroke. (Doenges et noncompliance. Therefore, re- Within the next 6 al., 2021, p. 502) months, the patient will education and referral to have well-controlled specialists may be necessary to blood pressure with a address these barriers and reading consistently promote adherence to medication below 130/80 mmHg. regimens. Risk for noncompliance Short-term goal: Develop a medication Work with the patient to with medication regimen schedule with the develop a medication New evaluation date/time: related to lack of Within the next 24 patient schedule that is easy to If the goal is met, a follow-up knowledge about hours, the patient will be Reinforce the follow and fits into their appointment will be scheduled in hypertension able to verbalize importance of daily routine. (Doenges et one month. If the goal is partially management. understanding of the medication adherence al., 2021, p. 504) met or unmet, a follow-up importance of Remind the patient about appointment will be scheduled in adherence to medication the potential consequences two weeks regimen. of noncompliance and encourage them to ask Long-term goal: questions if they have concerns about their Within the next 2 weeks, medications. (Doenges et the patient will al., 2021, p. 504) demonstrate compliance with her medication regimen, as evidenced by taking her Losartan 50mg tablet daily as prescribed. Risk for falls related to Short-term goal: Implement fall Implement interventions to dizziness as manifested prevention measures reduce the patient's risk for by the patient's complaint Within the next 12 Encourage the use of falls, such as using a bed of dizziness. hours, the patient will be assistive devices alarm or chair alarm, able to identify factors providing nonskid footwear, that trigger dizziness and ensuring that the episodes. patient's environment is free of tripping hazards. Long-term goal: (Doenges et al., 2021, p. 557) Within the next 2 weeks, Encourage the patient to the patient will be able use assistive devices, such to demonstrate as a walker or cane, to improved balance and improve their balance and coordination, as reduce the risk of falls. evidenced by no further (Doenges et al., 2021, p. reports of falls or near- 557) falls. Readiness for enhanced Short-term goal: Provide education about Use simple language to knowledge related to hypertension explain the causes, risk hypertension Within the next 24 management: factors, and potential management. hours, the patient will be Use visual aids consequences of able to verbalize hypertension. (Doenges et understanding of al., 2021, p. 504) hypertension, its Use visual aids, such as causes, and its pictures, diagrams, or management. videos, to enhance the patient's understanding of Long-term goal: hypertension management. (Doenges et al., 2021, p. Within the next 2 weeks, 505) the patient will be able to demonstrate knowledge of the benefits of lifestyle modifications and medication adherence to effectively manage hypertension.