HPN & CHF

RLE #1
ALABE, AQUINO, AQUINO, BINWAG,
TOLENTINO, ROSALES
HYPERTENSI
ON
Acute Pain related to Increased cerebral vascular pressure
as evidenced by changes in appetite
NIC NOC
1. Note client’s attitude toward pain
and use of pain medications,
including any history of
substance abuse.
2. Determine specifics of pain
(location, characteristics,
intensity (0–10 scale), onset and
duration). Note nonverbal cues.
3. Encourage and maintain bed rest
during acute phase.
4. Eliminate or minimize
vasoconstricting activities that
may aggravate headache
(straining at stool, prolonged
coughing, bending over).
1. Nurse was able to assess the
factors of the patient’s condition
2. Patient was able to verbalize the
severity of pain. Helpful to
determine the appropriate
therapy.
3. Provided safety measures for the
patient.
4. Complications was minimized
by preventing the increase of
cerebral vascular pressure.
5. Patient’s pain and discomfort
was reduced by decreasing the
stress stimuli.
Decreased cardiac output related to high blood pressure as
evidenced by Severe Headache
NIC
1. Monitor Blood Pressure,
take 3 readings 3-5
minutes apart
2. Maintain activity
restrictions such as bedrest
3. Instruct in relaxation
techniques, guided
imagery
4. Provide comfort measures,
such as back and neck
massage or elevation of
NOC
1. Provides accurate readings
of BP
2. Patient is now well rested
3. Patient was able to reduce
stress stimuli
4. Therapeutic massage was
able to decrease patient’s
discomfort
5. Patients blood pressure
Activity intolerance related to generalized weakness as evidenced by 5
abnormal HR/BP response to activity
NIC NOC
1. Assess the patient’s general • Determine the baseline of patient’s
condition. Note VS. general condition.
2. Note presence of factors • Patient will verbalize factors that
contributing to fatigue contributes to fatigue.
3. Ensure that clients change • Patient will verbalize understanding
position slowly. Monitor of the need to gradually increase
symptoms of activity activity based on testing, tolerance
intolerance. and symptoms.
4. Instruct patient in energy- • The patient will verbalize and
conserving techniques exhibit the use of energy-conserving
5. Instructe periods of rest techniques
before and after planned • Patient rests before and after
exertion periods such as
 Congestive
heart failure
Ineffective tissue perfusion related to decreased cardiac output 7as
evidenced by
coldNIC
clammy skin NOC
1. Monitored vital signs, Determined abnormal pulse
especially pulse and blood rate and high blood pressure
pressure • Reduced the energy
2. Established a quiet demands on the patient
environment. • Bedsores prevented

3. Reposition the patient every • Better peripheral circulation

2 hours
4. Encouraged peripheral • Enhances blood flow and
passive ROM decreased oxygen
5. Administered vasodilators consumption by the
Excess Fluid Volume related to Sodium and Water Retention 8

as evidenced by Bipedal Edema

NIC NOC
1. Monitored intake and • Determined the fluid
output imbalance as manifested
2. Elevated the affected by greater output
extremities • Reduced discomfort as
verbalized by the patient
3. Maintained on high- • Clear lung fields
Fowler’s position
4. Advised to limit fluid • Showed compliance to
intake fluid restrictions
• Increased urine output
Activity Intolerance related to imbalance between oxygen 9

supply and demand as evidenced by body weakness

NIC
1. Assessed client’s general
condition.
2. Elevated the head of the
bed.
3. Assisted the client in
ambulation
4. Provided assistance with
self-care activities as
indicated. I
5. Instructed the client in
unfamiliar activities and in • Relaxed the body and
NOC
• Noted for any
abnormalities and
deformities present.
• Maintained an open airway
• Prevents risk for falls that
could lead to injury
• Met patient’s personal care
needs without undue stress
and excessive oxygen
demand.
THANK YOU
AND
GOD BLESS!