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ACTUAL PROBLEM ASSESSMENT S: “kinanayon sumakit dytoy tiltil ko” O:  Conscious and coherent  Restless  Able to perform ADL’s

with assistance  Dizziness noted  Irritable in times  With initial vital signs of BP:180/120mmHg PR: 86 bpm RR: 36 bpm Temp: 36.6°c Acethylcoline released by prosta preganglionic neurons Preganglionic fiber releases Norepinephrine(constriction of blood vessel thereby increasing blood pressure adrenal medulla secrets epinephrine increased blood pressure causing it to increase blood supply in the brain causing occipital headache LTO: after 3 days of nursing interventions the client will maintain normal and stable blood pressure INTERFERENCE Stimulation of vasomotor center (loc in medulla) send impulses to CNS PLANNING STO: After 8 hours of nursing intervention the clients blood pressure will decreased to acceptable limits INTERVENTION  Assess underlying condition  Monitor blood pressure for every 30 mins  Observe skin color, temperature, capillary refill, and diaphoresis RATIONALE To determine what triggers the elevated BP Changes in BP may indicates changes in patients status requiring prompt medical attention Peripheral vasoconstriction may result in pale,cool,clammy skin,with prolonged capillary refill time It may decrease peripheral venous pooling that may potentiated by vasodilators and prolong sitting or standing EVALUATION STO: After 8 hours of nursing intervention the client has no elevation in his blood pressure Goal was met

 Do frequent positioning to the patient

LTO: after 3 days of nursing intervention the patient maintains a stable blood pressure Goal was met.

Dx: hypertension related to elevated blood pressure as manifested by occipital headache

 Administered prescribed drugs (anti-hypertensive)

 Inhibits influx of

 Encouraged pt to

Ca ion across cell membrane to produce relaxation of coronary smooth muscle
 This are cardiac 14

controlling it is the best way to stop it from reoccurring  Salty and fatty food are one of the common cause of hypertension 15 .  Encouraged patient to maintain low salt low fat diet stimulant and may adversely affect cardiac function  Hypertension is life time illness.decrease intakes of caffeine.and chocolate  Emphasize the concept of controlling hypertension rather than curing it. cola .

non stressful environment  Position patient in a trendelenburg position  Provide safety by raising the side rails LTO: After 3 days of nursing interventions the patient is now free from dizziness and able to do ADL’s without any fear from being injured.6°c  Assess level of consciousness  Monitor vital signs especially blood pressure  Limit activities and maintain quite. 16 .POTENTIAL PROBLEM ASSESSMENT S: INTERFERENCE Stimulation of vasomotor center (loc in medulla) send impulses to CNS Acethylcoline released by prosta preganglionic neurons Preganglionic fiber releases Norepinephrine(constriction of blood vessel thereby increasing blood pressure adrenal medulla secrets epinephrine vasoconstriction of bloodvessels causing it to release renin Dx: risk for injury related to hypertension as manifested by dizziness and body weakness angiotensin I conver to angiotensin II(vasoconstriction) secretion of aldosterone causing sodium and water to retained witch leads to increase intravascular volume LTO: after 3 days of nursing interventions the patient will be free from any sign of dizziness and will be able to perform ADL’s independently without any risk of accident  Monitor for the side effect of drugs given PLANNING STO: after 8 hours of nursing intervention the patient was able to remain safe from any possible injury INTERVENTIONS  Assess for general status RATIONALE  Ti determine what causes the dizziness and what health teaching to provide   To monitor patients status increase in BP indicates increased in cerebrovascular pressure  To determine if this drugs has something to do with the patients dizziness  This may help alleviate dizziness by letting the client have peaceful rest  Trendelenburg position facilitates easy back flow of blood from the heart  To prevent the patient from falling down in the bed EVALUATION STO: After 8 hours of nursing intervention the patient remain safe from injury O:  Conscious and coherent  Restless  Dizziness noted  Able to do ADL’s with assistance  Initial v/s of BP:180/120mmHg PR: 86 bpm RR: 36 bpm Temp: 36.

poor circulation less oxygen supply in the brain leads to dizziness  Encouraged to avoid sudden movement  Advised SO to always accompany the patient  Sudden movement aggravate the dizziness  to have somebody to help her whenever the dizziness will occur 17 .

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