ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE Evaluation

DIAGNOSIS

Subjective A. Headache Short Term Goal: A. Independent

1.Headache - Nursing definition: - Within 2-4hrs, patient -To gain Patient's Trust - After 2-4hrs, patient
2.Chest pain unpleasant sensory or will report decrease -Establish Rapport reports of pain relief,
emotional experience severity of headache (scale of 2 out of 10
of actual tissue and Chest pain - Determine the type of -to know the degree and severity
of pain to give a proper in pain scale)
damage. It a may be pain and pain scale,
sudden or slow onset, - Within 2-4hrs, severity, location of pain. medication for pain
mild to severe patient’s blood
Objective pressure would have - Check his/ her Vital - to know the Blood pressure of - Patient became
-Pale, weak looking, come to the normal signs the patient to get the right vital calm and relaxed.
heavy perspiration expected BP range of PR or pulse rate signs if there are any
As evidenced by
the patient (120/80) RR or respiratory rate abnormalities
throbbing pain in the
-Restless, hands Oxygen level by using
head, loss of appetite, - Patient has better
holding the chest pulse oximeter
neck stiffness, blurred posture and
then the head
vision, nausea and disposition.
Monitor and record BP. -World Health Organization
vomiting
-Pain Scale 6/10 Measure both arms and (WHO) guidelines recommend
Long Term Goal: thighs three times, 3–5 that the blood pressure (BP)
-Elevated blood min apart while the should be routinely measured in - Blood pressure
pressure (150/90) B. Chest Pain - Patient will have a sitting or supine followed by comes down to
patient is at rest, then
- Nursing Definition: better understanding of standing position,
sitting, then standing for 120/80
T 37.2 chest tightness or high blood pressure, its initial evaluation.
discomfort in the causes, risk and - to ensure a correct diagnosis
PR 84 center or the left side possible complications
RR 18 of the chest that may
be accompanied by To Know if there is presence of
- Auscultate heart tones
shortness of breath crackles and wheezes may
and breath sounds.
- Patient will indicate pulmonary congestion <Patient went to
understand the secondary to developing or follow-up one week
As evidenced by high chronic heart failure. after ER consult;
importance of proper
BP, restlessness and
nutrition: low fat, low
guarding behavior by -Observe skin color, - The presence of pallor; cool, Patient went to follow
sodium, high fiber diet
holding the chest moisture, temperature, moist skin; and delayed capillary consult after 3
and capillary refill time refill time may be due to months and 6
peripheral vasoconstriction or months for further
-Patient will understand reflect cardiac decompensation monitoring>
the importance of and decreased output.
physical activity and
exercise - Patient was able to
understand
about his disease,
high blood pressure,
its causes, and
- Ask about their -To determine and rule out reduced risk factors
sedentary lifestyle worsening of underlying condition (if present such
and prevent complications lifestyle, vices, etc),
to prevent possible
- Note about the history - To eliminate and complications
of alcoholism and prohibit contributory factors
smoking

- Check laboratory data -To identify contributing factors

(cardiac markers, - Patient was able to
complete blood cell understand the
count, electrolytes, importance of
ABGs, blood urea physical activity and
nitrogen and creatinine, exercise hence,
cardiac enzymes, and patient has exercise
cultures, such as blood, regimen such
wound, or secretions walking, biking for 30
mins, 3x a week

Advise the patient to - To eliminate and prohibit

cease smoking and to contributory factors
reduce alcohol intake
- Patient was able to
-Provide correct -To ensure proper health understands the
information about the education about the disease importance of proper
disease process, nutrition: low fat, low
prognosis, and the proper sodium, high fiber
treatment regimen. diet
<Patient changed
eating habits &
- Educate the patient -To boost a healthy lifestyle adhere to DASH
about lifestyle diet>
modification implement
regular physical activity
and proper exercise
everyday
Limiting sodium and sodium- rich
-Evaluate patient’s processed foods can help
healthy diet manage fluid retention and, with
- Educate patient with associated hypertensive
regards to correlation response, decrease myocardial
between hypertension workload. A balanced diet
and obesity.
lower in calories, fat, and sodium
- Advise decrease caloric
and rich in calcium,
intake, low sodium, low
sugar, high fiber diet potassium, and magnesium may
help lower BP

- encourage about DASH

(Dietary Approaches to -to help develop a plan for
Stop Hypertension) diet improving diet weight plan and
includes consumption of increase nutrient intake for weight
a diet rich in fruits, loss also.
vegetables, and low-fat
dairy.
Rich in potassium,
calcium, magnesium, To provide non-pharmacologic
fiber and protein management to control the high
Low in saturated fat blood pressure
Low in sodium
- To provide relaxation and
- Encourage head/neck reduce tension
massage, back rubs, cool
cloths, avoiding bright - Response to drug therapy is
light dependent on both the individual
and the synergistic effects of the
- Encourage Rest and drugs. Because of side effects,
Sleep drug interactions, and patient’s
motivation for taking
- Monitor response to antihypertensive medication, it is
medications to control important to use the smallest
blood pressure. number and lowest dosage of
medications.
 -to help achieve a normal blood
pressure

Keeping an organized record of

Assist patient to have BP readings and medications
effective evaluation and empowers the patient and
monitoring provides accurate information to
Motivate patients to the practitioner.
assess and manage their
blood pressure, and Use
correct technique to Lack of cooperation is common
measure blood pressure reason for failure of
antihypertensive therapy
-Give the patient a
logbook or piece of paper
to record BP
measurement and the -To ensure proper adherence to
time it is taken. the antihypertensive therapy

-Reinforce the
importance of adhering to
treatment regimen and
keeping follow-up
appointments - To ensure adherence to non-
Encourage frequent pharmacologic ang
follow up or check up at pharmacologic therapy
least every 3 mos.

-Provide the patient with

printed instructions with a
written or pictorial guide Drugs used to treat hypertension
appropriate to the work to alter the normal reflexes
patient’s health literacy that control blood pressure.
level. Treatment for essential
hypertension does not cure the
- Build Therapeutic disease but aimed at maintaining
Alliance with Family or the blood pressure within normal
with Significant others limits to prevent the damage that
hypertension can cause.
 Focus on Nursing Pharmacology
B. Dependent by Amy M.Karch page 674

-provide a proper
medication ARBs are competitive
as Prescribed by the inhibitors of aldosterone binding.
physician. to block the blood pressure
raising effect of the renin-
angiotensin-aldosterone system
-Angiotensin II-Receptor (RAAS).
Blockers (ARBs)
irbesartan (Avapro) ACE inhibitors inhibit the
losartan (Cozaar) conversion of angiotensin I to
telmisartan (Micardis) angiotensin II and lowers
valsartan (Diovan) peripheral resistance

Angiotensin-Converting
Enzymes (ACE)
Inhibitors Beta blockers block the
benazepril (Lotensin) sympathetic nervous system to
captopril (Capoten) produce a slower heart rate and a
enalapril (Vasotec IV) lower blood pressure.
quinapril (Accupril)

Beta Blockers
atenolol (Tenormin)
bisoprolol
(Cardicor, Emcor)
carvedilol. Decrease blood pressure, cardiac
metoprolol workload, and myocardial
(Betaloc, Lopresor) consumption of oxygen.
nebivolol (Nebilet) can significantly decrease cardiac
propranolol (Inderal) workload, they are effective in
treatment of angina.
Calcium-Channel
Blockers
amlodipine (Norvasc)
diltiazem
(Diltiazem)nicardipine
(Cardene)
nifedipine (Adalat,
Procardia)
verapamil (Calan, Isoptin) Diuretics are considered first-line
medications for uncomplicated
stage I or II hypertension and
Diuretics may be used alone or in
association with other drugs
Thiazide diuretics: (such as beta-blockers) to reduce
chlorothiazide (Diuril); BP in patients with relatively
hydrochlorothiazide normal renal function. These
(Esidrix/HydroDIURIL); diuretics potentiate the effects of
bendroflumethiazide other antihypertensive agents as
(Naturetin); well, by limiting fluid retention,
indapamide (Lozol); and may reduce the incidence of
metolazone (Diulo); strokes and heart failure.
quinethazone
(Hydromox). These drugs produce marked
diuresis by inhibiting resorption of
sodium and chloride and are
effective antihypertensives,
especially in patients who are
resistant to thiazides or have
Loop diuretics: renal impairment.
furosemide (Lasix);
ethacrynic acid (Edecrin); May be given in combination with
bumetanide (Bumex), a thiazide diuretic to minimize
torsemide (Demadex). potassium loss.

Potassium-sparing
diuretics:
spironolactone Vasodilators are medications that
(Aldactone); triamterene open (dilate) blood vessels.
(Dyrenium); amiloride Exert their effect by acting
(Midamor). directly on smooth muscles.
Consequently, there will be
Vasodilators muscle relaxation and
hydralazine (Apresoline) vasodilation. Both of these will
minoxidil (Loniten) cause drop in blood pressure.
nitroprusside (Nitropress)
nitroglycerin
 CXR provides important
information of associated target
C. Collaborative organ damage in hypertensive
patients
- Check patient’s
diagnostic findings CBC may indicate anemia due
Chest x- ray, disease
Complete blood count,
Plasma glucose, determine blood glucose levels, a
Serum potassium, possible concomitant
Sodium co-morbidity (diabetes).
Calcium,
Uric acid,
Plasma renin, Blood urea nitrogen- determine if
Thyroid function tests, renal dysfunction or fluid
imbalances are present as a
complication of hypertension
Urinalysis
Blood urea nitrogen, Serum creatinine- determines if
Serum creatinine, renal dysfunction is present as a
complication of hypertension

Monitor electrolyte imbalance that

- Advise decrease caloric is caused by fluid overload such
intake, low sodium, low as increased sodium levels or
sugar, high fiber diet decreased potassium.
as recommended by the
doctor and administer by Monitor renal values that show
the dietician or nutritionist evidence of fluid retention: BUN,
creatinine, urine specific gravity.
-as prescribed by the
doctors Total cholesterol- used for
and administer by other screening to determine risk of
health allied profession or coronary heart disease, assesses
team (Referral to care for hyperlipidemia.
team services)
Refer to PT, cardiac Triglycerides- used for screening
rehab, or local programs and initial classification of risk of
coronary heart disease,
elevations determine
hyperlipidemia.

Electrocardiogram- Electrical
conduction system may be
altered by hypertrophied left
ventricle.

Limiting sodium and sodium- rich

processed foods can help
manage fluid retention and, with
associated hypertensive
response, decrease myocardial
workload. A balanced diet
lower in calories, fat, and sodium and
rich in calcium,
potassium, and magnesium may help
lower BP

Patients who require a more

supervised approach may need
PT evaluation for safety
modifications.
Cardiac rehab teaches exercise
training specific to heart health.
Patients may also find support
from their local gym or programs
that offer free or low-cost classes