Ralph Sydney C.

Pagaduan

Case Scenario: Ryan Johnson, 42, visits the emergency department with complaints of increasing shortness of breath, exhaustion, and chest
discomfort in recent months. She also mentions lightheadedness and near-fainting events on occasion. She has no substantial medical history, is
a nonsmoker, and drinks alcohol on occasion. Emily denies having any recent diseases or having traveled to high altitudes. Emily's vital signs
were taken as follows: blood pressure is 130/80 mmHg, heart rate is 100 bpm, respiratory rate is 24 bpm, the temperature is 36.7, oxygen
saturation (Sp02) is 89% on room air.

Nursing Problem: Pulmonary hypertension

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Ineffective After 8 hours of nursing  Administer oxygen  To enhance After 8 hours of
• Patient-reported Tissue Perfusion intervention, the therapy. oxygenation nursing
symptoms such as related to patient will be able to and manage intervention, the
shortness of increased improve oxygenation hypoxemia. It goal was met, the
breath, fatigue, pulmonary vascular and ventilation, helps to boost patient was able to
chest pain, and resistance alleviate symptoms, and blood oxygen improve
lightheadedness. secondary to enhance knowledge and levels, lowering oxygenation and
Non-smoker, pulmonary understanding of the the load on the ventilation,
occasional alcohol hypertension. disease. right ventricle alleviate
consumption and minimizing symptoms, and
hypoxia enhance
OBJECTIVE: symptoms. knowledge and
VITAL SIGNS WERE understanding of
AS FOLLOWS;  Elevating the the disease.
Blood Pressure: head of the bed
130/80 mm Hg and promoting
Heart Rate: 100  Elevate the head a comfortable
bpm part of the bed of position can
Respiratory Rate: the patient. help with chest
24 expansion,
bpm dyspnea
Temperature: reduction, and
98.6°F lung function
(37°C) enhancement.
Oxygen Saturation Proper posture
(Sp02): 89% on improves
room air oxygen
exchange in the
lungs.

 Continuous
monitoring of
vital signs
facilitates in the
detection of
changes in the
patient's
 Monitor vital signs condition.
Elevated heart
rate, blood
pressure, or
respiration rate
can all indicate
increasing
symptoms or
effects allowing
for prompt
treatment.

 Maintaining a
strict intake and
output records
aids in fluid
balance
management.
This is
significant
 because
 Monitor fluid intake excessive fluid
and output for fluid can induce right
balance sided heart
management failure and
worsen
pulmonary
hypertension.

 Assessing and
controlling
chest pain is
vital for
reducing
discomfort and
anxiety. Pain
treatment
improves
patient comfort
 Manage pain and well-being.

 Patient education
helps patients
understand
pulmonary
hypertension,
how to manage
it, and the need
of sticking to a
treatment plan.
Patient who are
more educated
are more likely
 Educate the patient to participate
 about the disease actively in their
care and adhere
to advise
lifestyle
changes.

 To minimize
pulmonary
vascular
resistance,
relieve right
venticular
strain, and
control fluid
retention,
medication such
as vasodilators
and diuretics
are medication
such as
vasodilators and
diuretics are
administered.
 Administer This
medication as medications are
ordered. designed to
increase cardiac
output while
decreasing the
stress on the
heart.