ASSESSMENT

Subjective : sumasakit ang batok ko at nahihilo ako as verbalized by the client Objective: Afebrile Cold clammy skin Dyspnea Restlessness Variations in blood pressure Blood pressure of 190/150 mmHg Lethargic Decreased cardiac output Oxygen saturation of 89 %

NURSING DIAGNOSIS
Output r/t malignant hypertension as manifested by decreased stroke volume

ANALYSIS

GOALS AND NURSING RATIONALE OBJECTIVES INTERVENTIONS

To gain pts trust To obtain History Taking Assess (BP, patients condition Review lab data Review ECG strip To determine present condition For comparison with normal values baseline data To determine contributing factors NI, the pt will manifest hemodynamic stability Monitor Vital Signs

EVALUATION EFFECTIVENESS _ client pain was lessened __ client was able to perform deep breathing exercise __ client able to perform management Yes_ No_ Why_ EFFICIENCY Were the resources available to the nurse and client maximized economically? Yes_ No_ Why_ APPROPRIATENESS Were the interventions appropriate to the client? Yes_ No_ Why_ ACCEPTABILITY Were all the interventions settings and timetable acceptable to the client

Decreased Cardiac Hypertension is After 6 hours of Establish Rapport defined as a condition wherein there is an increase in BP beyond the normal range. Hypertensive emergency is used for BPs above 160/100mmHg. With hypertension, the blood vessels constrict. When blood vessels are constricted, there is a decrease in Encourage to increase Provide PM care

CO, UO, PR) pt shall verbalize understanding of also

Monitor BP, PR the disease frequently . process & risk Provide information factors Long on test procedures Term: After 4 days of NI, the pt participate activities decrease pressure. Explain dietary will restrictions Encourage rest & that reposition client q2 blood Encourage relaxation techniques in

To determine alterations in electrical activity of the heart

To note response to

blood volume, decrease in cardiac output and increase in BP as blood passes through the narrowed lumen of the vessels.

activity level as tolerated Teach home BP reading & monitoring Administer anti hypertensives

activity To gain pts participation & decrease anxiety level To inform patient of contributing factors To decrease stress and promote venous return

situations? Yes_ No_ Why_

ADEQUACY Were the numbers of the interventions enough to solve the health problem? Yes_ No_ Why

To alleviate anxiety & stress

To promote hygiene & comfort

To maintain functional

ability

To detect change in VS & seek timely intervention To decrease BP within normal ranges