St.

Anthony’s College
San Jose, Antique
Nursing Department
NAME:M.L.H.
AGE:55 years old
Dr.: Dr. Baria
CC: NURSING CARE PLAN
CUES NURSING RATIONALE PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE: Inadequate blood GENERAL: After 8 INDEPENDENT:
“Nagataas akon BP.” As pumped by the heart hours of Nursing Review clients at risk as noted Persons with acute or chronic Goals patially met.
verbalized by the patient. Risk for decrease to meet metabolic intervention, the in Related Factors as well as conditions may compromise
demands of the body. patient will be able to individuals with conditions that circulation and place
cardiac output. maintain BP within stress the heart. excessive demands on the
individually heart.
acceptable range.
Check laboratory data (cardiac To identify contributing
OBJECTIVE: markers, complete blood cell factors.
Bp: 150/90 count, electrolytes, ABGs, blood
PR: 119bpm urea nitrogen and creatinine,
RR: 15 cardiac enzymes, and cultures,
such as blood, wound or
secretions).

Monitor and record BP. Comparison of pressures

Measure in both arms and thighs provides a more complete
three times, 3–5 min apart while picture of vascular
SPECIFIC: patient is at rest, then sitting, involvement or scope of
After 2 hours, the then standing for initial problem. Severe hypertension
patient will be able to evaluation. Use correct cuff size is classified in the adult as a
participate in and accurate technique. diastolic pressure elevation to
activities that reduce 110 mmHg; progressive
BP/cardiac workload. diastolic readings above 120
mmHg are considered first
accelerated, then malignant
(very severe). Systolic
hypertension also is an
established risk factor for
cerebrovascular disease and

Note presence, quality of central
and peripheral pulses.
DEPENDENT:
Alpha, beta, or centrally
acting adrenergic
antagonists: doxazosin
(Cardura); propranolol (Inderal);
acebutolol (Sectral); metoprolol
(Lopressor), labetalol
(Normodyne); atenolol
(Tenormin); nadolol
(Corgard), carvedilol (Coreg);
methyldopa
(Aldomet); clonidine (Catapres);
prazosin (Minipress); terazosin
(Hytrin); pindolol (Visken);
ischemic heart disease, when
diastolic pressure is elevated.
Bounding carotid, jugular,
radial, and femoral pulses may
be observed and palpated.
Pulses in the legs and feet may
be diminished, reflecting
effects of vasoconstriction
(increased systemic vascular
resistance [SVR]) and venous
congestion.
Beta-Blockers may be ordered
instead of diuretics for patients
with ischemic heart disease;
obese patients
with cardiogenic hypertension;
and patients with concurrent
supraventricular
arrhythmias, angina, or
hypertensive cardiomyopathy.
Specific actions of these drugs
vary, but they generally
reduce BP through the
combined effect of decreased
total peripheral resistance,
reduced cardiac output,
inhibited sympathetic activity,
and suppression of renin
release. Note: Patients
with diabetes should use
Corgard and Visken with
caution because they can
prolong and mask the
hypoglycemic effects
of insulin. The elderly may
require smaller doses because
of the potential for
bradycardia and hypotension.
African-American patients
tend to be less responsive to
beta-blockers in general and
may require increased dosage
or use of another drug
(monotherapy with a diuretic).