NCP Beea

Republic of the Philippines
WESLEYAN UNIVERSITY-PHILIPPINES
COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES
NURSING CARE PLAN 1 3100 Sampaguita St. Cabanatuan City, Nueva Ecija
ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Objective Data: Risk for decreased Short term: 1. Keep an eye on the client's 1. Aims to alleviate and early Short term:
cardiac output related to vital signs and oxygen identify heart complications.
 Shortness of breath increased vascular After 2 hours of nursing saturation all the while. After 2 hours of nursing
accompanied by resistance secondary to intervention, the client intervention, the client has
coughing vasoconstriction and reduces vascular resistance 2. Take note of the peripheral 2. to recognize the elevated decreased blood pressure
 Fatigue Increase pressure within thereby decreased blood pulses' rate, rhythm, and systemic vascular resistance,
 Apical pulse the blood vessels pressure quality. manage it, and avoid venous
increased congestion
 Chest Auscultation Long term:
reveals presence of 3. Determine the real origin 3. to address the underlying cause
murmurs Long term: of hypertension and of hypertension in in order to After 2 days of nursing
 Vital Sign: manage it maintain a normal cardiac intervention, the client did
BP: 180/95 After 2 days of nursing output not develop complications
intervention, the client as evidenced by normal
demonstrates a stable 4. Establish a soothing, 4. to lower BP by reducing blood pressure and
Method: Physical cardiac parameter by peaceful setting sympathetic stimulation and acceptable cardiac
examination maintaining blood pressure encouraging relaxation parameters.
within the acceptable
range. 5. Schedule regular periods of 5. to lessen the impact of stress
adequate relaxation and and exhaustion on blood
exercise, as well as proper pressure
bedrest.
6. Continue to keep an eye on 6. To regulate blood pressure by

the patient and give them reducing vascular resistance
their prescription anti- and decreasing
hypertensive medications. vasoconstriction
7. lowering the blood pressure in
7. Encourage the customer to order to reduce vascular
closely adhere to the resistance and myocardial
recommended dietary workload
limits for fats, salt, and
cholesterol.
8. To prevent shortness of breath
8. In the situation that the
saturation levels are low,
provide oxygen as
prescribed.
9. To lower stress and blood
9. Provide light music as a pressure by calming the mind
sort of diverting and and body.
relaxation therapy.
10. To reduce myocardial strain
10. As prescribed, provide and venous congestion
diuretics like Lasix
ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
Objective Data: Imbalanced Nutrition, Short term: 1. Assess the client's dietary 1. Assessment supports Short term:
more than body After 1 hour of nursing patterns. diagnostic and intervention After 1 hour of nursing
 Weight requirements related to intervention the patient planning intervention the patient
Gain excessive food Intake will understand the understands the
 BMI- in relation to the importance of healthy life 2. daily check of the vital signs, 2. to determine the client's importance of healthy
Obese metabolic needs and style BMI, and weight nutritional status life style
 Cholesterol sedentary lifestyle
level causing obesity leading Long term: 3. Encourage the client to eat a 3. To lower blood pressure and Long term:
Increased to compression diet high in fiber and healthful lower the risk of developing
 Triglycerid pressure in the blood After 7 days of nursing foods like fruit, vegetables, heart disease After 7 days of nursing
e increase vessels intervention, through and greens. intervention, Client
 VLDL & consistent exercise, clients maintained a normal
LDL show a change in their 4. Encourage the customer to 4. To decrease obesity nutritional pattern as
increase eating habits and maintain consume vitamin D and evidence by gradual
 HDL- a healthy weight. Omega 3 fatty acid-rich foods decreased in weight and
Decrease like fish oils. control of blood
pressure and modifying
 Vital signs:
5. Encourage the customer to 5. to reduce blood pressure and lifestyle habits
BP: 180/90
stay away from dietary sources weight
of cholesterol including fast
food and fried, fatty items.
Method: Physical
examination
6. Encourage the customer to 6. To lower blood pressure
reduce daily salt consumption
and stay away from packaged
and processed meals.
7. Encourage the customer to 7. To maintain hydration and

consume 1200–1500 ml of prevent over weight
fluids each day.
8. Encourage the client to stop 8. To reduce the accumulation of

smoking cigarettes and unhealthy fat in blood vessels
chewing tobacco. and reduce the risk of high
blood pressure.
9. Encourage the client to engage 9. To control body weight

in regular aerobic activity,
such as brisk walking, for at
least 30 minutes each day.

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NCP Beea

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Republic of the Philippines

COLLEGE OF NURSING AND ALLIED MEDICAL SCIENCES

ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION

6. Continue to keep an eye on 6. To regulate blood pressure by

7. Encourage the customer to 7. To maintain hydration and

8. Encourage the client to stop 8. To reduce the accumulation of

9. Encourage the client to engage 9. To control body weight

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