ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

BACKGROUND
Subjective: Risk for Short term: Independent: Independent: Short term:
-general impaired Unhealthy 1.Assess and 1.It helps to
weakness cardiac function lifestyle record vital signs identify
After 6 hours, After 6 hours, the
-headache related to including diet, the client will regularly, also occurring and client had no
-difficulty in hypertension as vices, and have no including heart reoccurring elevation in blood
exercising evidenced by activities. elevation in sounds and conditions. pressure and it was
-inappropriate elevated blood blood pressure rhythms. 116/70 mmHg,
eating habits pressure that above the 2.It may be an which was within
-smoking ranges from High total 2.Investigate indicative of
normal limits the acceptable
cigarettes 150-155/110-11 cholesterol (bad) reports of oxygen exchange
and will be range. Furthermore,
mmHg, and high within the difficulty in problems with the client had
weakness, triglycerides acceptable breathing. potential for experienced
Objective: headache, and range. cardiopulmonary dizziness upon
-moderate laboratory tests Plaques (fat, 3.Discuss risk dysfunction. standing and sitting
obesity showing high factors (ex. family and some minimal
cholesterol, and
(height=5ft 6in, total cholesterol history, obesity, 3.This is signs of difficulty
other substances)
weight= 150 lbs) (268 mg/dL) Long term: age, smoking) and necessary for the performing
-minimal and high buildup on the encourage healthy client to make
After 1 week of movements or
retinopathy triglycerides arteries lifestyle/activities informed risk
nursing activities such as
(230 mg/dL). such smoking factors and to walking and also
Laboratory test interventions, cessation, proper commit lifestyle experienced
includes the ff: High blood the client will diet, weight changes dizziness upon
-serum sodium: pressure verbalize maintenance and necessary. standing and sitting,
138 mEq/L (hypertension) knowledge on exercise. thus the goal was
-potassium: 3.4 adding stress taking control 4. Facilitates partially met.
mEq/L speeds up the of hypertension, 4. Instruct in blood management of
-blood urea clogging in individual risk pressure hypertension,
nitrogen (BUN): arterial walls. factors, and monitoring at which is a major
19 mg/dL organizing a home if indicated; risk factor for Long term:
-creatinine: 0.9 Atherosclerosis plan for a advise purchase of damage to blood
After 1 week of
mg/dL healthy and home monitoring vessels or organ
nursing
-calcium: 9.8 equipment/refer to function.
Heart Attack effective interventions, the
mg/dL community
treatment. client was able to
-total cholesterol: resources as
268 mg/dL needed. verbalize her own
-triglycerides: knowledge on taking
230 mg/dL control of
-fasting glucose: hypertension, said
105 mg/dL “ah kailangan ko
pala imonitor ang
Vital signs taken pressure ko, kung
as follows: hindi baka atakihin
-Temp: ako ng puso, mas
-HR:
mainam kung
-PR:
mabantayan” and
-BP: 150 to
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
BACKGROUND
Subjective: Risk for decreased Short term: Independent: Independent: Short term:
-general cardiac tissue Unhealthy 1.Investigate 1.To evaluate for
weakness perfusion related lifestyle After 5 hours of reports of chest potential After 5 hours, the
-headache to inadequate including diet, nursing pain, noting myocardial client still had an
-lack of exercise knowledge of vices, and interventions, changes in ischemia or elevation in her
-inappropriate modifiable risk activities. the client will characteristics of inadequate blood pressure and
eating habits factors as demonstrate pain. systemic also showed the
-smoking evidenced by adequate oxygenation or presence of
Hyperlipidemia
cigarettes moderate obesity coronary 2.Investigate perfusion of dysrhythmias, thus
and
(height=5ft 6in, perfusion as reports of organs. the goal was not
weight= 150 lbs), hypertension individually difficulty in met.
Objective: sedentary lifestyle, appropriate. breathing. 2.It may result in
-moderate hypertension (BP: cardiac Long term:
obesity 150 to 155/110 to Atherosclerosis Long term: 3. Monitor vital dysrhythmias
(height=5ft 6in, 114 mmHg), and (blockage or signs, especially and cardiac After 8 days, the
weight= 150 lbs) hyperlipidemia clogging) After 8 days of noting blood dysfunction if client willfully
-minimal (total cholesterol: nursing pressure changes not monitored engaged in healthy
retinopathy 268 mg/dL, interventions, lifestyles and
triglycerides: the client will 4. Provide 3. It helps to behaviors,
Laboratory test 230 mg/dL). Insufficient supplemental identify
demonstrate demonstrating
includes the ff: oxygenation and oxygen as occurring
behaviors and positive participation
-serum sodium: nutrition of indicated conditions
lifestyle in activities
138 mEq/L tissues changes to including smoking
-potassium: 3.4 maintain or 5. Provide periods 4. To improve or cessation, proper
mEq/L maximize of undisturbed rest maintain cellular diet, and weight
-blood urea Organ damage or and calming function
circulation. management.
nitrogen (BUN): dysfunction environment 5. To reduce Moreover, the client
19 mg/dL stress and was able to ask
-creatinine: 0.9 6.Discuss myocardial about the prescribed
mg/dL cumulative effects workload medication’s use,
-calcium: 9.8 of risk factors (ex. effectiveness, and
mg/dL family history, 6.To assist undesirable effects,
-total cholesterol: obesity, age, client/significant which then showed
268 mg/dL smoking) and other in the client’s
-triglycerides: encourage healthy understanding eagerness for the
230 mg/dL lifestyle/activities those areas in treatment. Therefore,
-fasting glucose: such smoking which they can the goal is met.
105 mg/dL cessation, proper take their action
diet, weight or make a
Vital signs taken maintenance and healthy choice.
as follows: exercise.
-Temp: 7. To manage
-HR: 7. Review those that affect
-PR: medications on cardiac function,
-BP: 150 to regular basis. or blood
155/110 to 114 pressure.
 ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION
BACKGROUND
Subjective: Ineffective Short term: Independent: Independent: Short term:
-smoking cigarettes health Unhealthy
-difficulty in management lifestyle 1.Assess and 1.It helps to
After one day After one day, the
exercising related to including diet, of nursing record vital signs identify client verbalized,
-inappropriate difficulty vices, and interventions, regularly occurring and “Susubukuan ko
eating habits managing activities. the client will reoccurring munang unti-untiin
-expression of complex verbalize 2.Identify conditions. ang paninigarilyo ko
dissatisfactions on treatment acceptance of individual nurse, hanggang
the side effects of regimen as Increasing blood perceptions and 2.May reveal
need and desire matanggal ko na
prescribed evidenced by pressure to change expectations of client’s thinking talaga sakin, para sa
medicines expression of actions to treatment regimen. about regimen, anak ko” and other
dissatisfactions No regular check- achieve agreed- Active-listen misinformation, positive remarks
Objective: on the side ups on health goals. client’s concern unrealistic towards changing an
-improper weight effects of and comments. expectations, or inappropriate
management; prescribed Long term: other factors that lifestyle.
Lack of
moderate obesity medicines, 3. Provide positive may interfere.
action/knowledge
(height=5ft 6in, chronic After one week reinforcement for Long term:
weight= 150 lbs) hypertension, for treatment efforts. 3. To encourage
of nursing
-chronic and ineffective interventions, continuation of After one week, the
hypertension choices in Substance/drug the client will 4. Mobilize desired client was insisted
- failure to attend daily living for misuse participate and support systems, behaviors. on positivity in
regular meeting health demonstrate the including engaging herself in a
appointments with goal, such bad behaviors and family/significant 4. Success of a healthy lifestyle and
healthcare provider diet and lack lifestyle others, social therapeutic voluntary
Chronic
-substance/drug of physical changes services, and regimen is participation in
hypertension
misuse exercise. necessary to financial enhanced using necessary health
-failure to take and other assistance. support system
occurrences maintain the practices with health
action that reduces therapeutic effectively. professionals.
risk factor such
regimen.
-ineffective choices hypercapnia,
in daily living for or
meeting health hypokalemia
goal, such bad diet
and lack of
physical exercise

Laboratory test
includes the ff:
-serum sodium:
138 mEq/L
-potassium: 3.4
mEq/L
-blood urea
nitrogen (BUN): 19
mg/dL