Assessment Nursing Planning Nursing Rationale Evaluation

Diagnosis Intervention
SUBJECTIVE: Risk for prone Short Term: INDEPENDENT: Provides basis After 8 hours
“Bakit kaya behavior After 8 hours •Define and for of nursing
madalas related to lack of nursing state the limits understanding interventions,
sumasaskit ulo of knowledge interventions, of desired BP. elevations of the patient
ko at about the the patient will Explain BP, and was able to
nahihilo?” as disease. verbalize hypertension clarifies verbalize
verbalized by understanding and its effect misconceptions understanding
the patient. of the disease on the heart, and also of the disease
process and blood vessels, understanding process and
treatment kidney, and that high BP treatment
OBJECTIVE: regimen. brain. can exist regimen.
without
•Request for •Assist the symptom or
information. patient in even when
•Agitated identifying feeling well.
behavior modifiable risk
•Inaccurate factors like diet •These risk
follow through high in sodium, factors have
of instructions. saturated fats been shown to
•V/S taken as and contribute to
follows: cholesterol. hypertension.
T: 36.3 C
PR:82bmp •Reinforce the •Lack of
RR:21 bmp importance of cooperation is
BP: 140/90 adhering to common
mmHg treatment reason for
regimen and failure of anti-
keeping follow hypertensive
up therapy.
appointments.
•Decreases
•Suggest peripheral
frequent venous pooling
position that may be
changes, leg potentiated by
exercises when vasodilators
lying down. and prolonged
sitting or
•Help patient standing.
identify
sources of •Two years on
sodium intake. moderate low
salt diet may
•Encourage be sufficient to
patient to control mild
decrease or hypertension.
eliminate •Caffeine is a
caffeine like in cardiac
tea, coffee, stimulant and
cola and may adversely
chocolates. affect cardiac
function.
•Stress
importance of •Alternating
accomplishing rest and
daily rest activity
periods. increases
tolerance to
DEPENDENT: activity
Give due progression.
medications
•Refer to drug
study.