Patient: Ruben

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Risk for unstable blood After 8 hours of nursing • Note client reports • These symptoms After 8 hours of nursing
The patient stated that pressure related to intervention, the of headaches, may indicate that intervention, the
he has hypertension hypertension as patient will be able to: blurred visions, blood pressure is patient was able to
evidenced by • verbalize chest pain, elevated (although verbalize understanding
OBJECTIVE: fluctuations in blood understanding of weakness or high blood pressure of the disease process
• Vital signs taken as pressure levels the disease process numbness in arms, often fails to and treatment regimen
follows: and treatment legs, or face produce any and maintain blood
T: 36.0 regimen noticeable pressure levels within
PR: 62 • maintain blood symptoms until acceptable limits
RR: 20 pressure levels damage to the
B/P: 180/100 within acceptable blood vessels
O2Sat: 98% limits results in serious
conditions, or blood
pressure rise is
sudden

• Ascertain client’s • It is a good way to

current and ongoing actively manage the
blood pressure patient’s health
measurements,
noting trends, and
sudden changes

• Discuss with patient • These risk factors

the risk factors that can be changed in
are modifiable such order to prevent
as diet, lifestyle, and manage
taking medications hypertension
as prescribed and
avoiding substance
misuse/abuse

• Recommend • To enhance safety

changing position and reduce
from supine to gravitational blood
Patient: Ruben

standing slowly and pooling in the lower

in stages, avoiding extremities
standing for long
periods of time

• Instruct patient in • This will help in

healthy eating and preventing
adequate fluid functional decline
intake