Assessment Diagnosis Goals of Care (Planning) Interventions Rationale Evaluation

Cues Decreased cardiac Short term: Independent: Short term:

Subjective output related to
increased body weight After 2 hours of nursing 1. Established rapport to the 1. To gain the trust and After 2 hours of nursing interventions,
“Help us, my daughter as evidenced by blood intervention, the patient will achieve patient and relative. cooperation of the the patient achieved the following:
has a severe headache pressure of 150/100 the following: patient and relative.
and sudden fatigue,” mmHg, RR: 21 cpm, ● Verbalized relief with the use
temperature of 36.7 ● Verbalize relief with the use of non-pharmacological
(+) family history of DM and weight of 60 kg. of non-pharmacological 2. Obtained and monitored 2. To know if there are nursing interventions: “I feel
type 2 nursing interventions vital signs. changes in vital better, Doc.” the patient said.
● Display stable and normal signs.
Objective vital signs: ● Displayed stable and normal
○ Lower and maintain vital signs:
● BP: 150/100 blood pressure 3. Provided calm, restful 3. To help lessen ○ Lowered and
● Oxygen within individually surroundings, minimize sympathetic maintained blood
Saturation: 97% acceptable range environmental activity and stimulation; pressure within
● RR: 21 cpm (150/100 to 130/80 noise. Restrict the number promotes relaxation. individually acceptable
● PR: 59 bpm mmHg) of visitors and length of range of 130/80 mmHg
● Temperature: 36.7 ○ Demonstrate stable stay. ○ Demonstrate stable
● Weight: 60 kg cardiac rhythm and cardiac rhythm and
● Restless rate from 59 bpm to rate of 74bpm
70 bpm 4. Maintained activity 4. To lessen physical ○ Exhibit normal
○ Exhibit normal restrictions (bed rest or stress and tension respiration as
respiration as chair rest); assist patient that affect blood evidenced by: 18cpm
evidenced by: 12-20 with self-care activities as pressure and the
cpm needed. course of Long term:
hypertension.
After 1 week of nursing interventions,
Long term: the patient achieved the following:
5. Provided comfort 5. To decrease
After 1 week of nursing intervention, measures (back and neck discomfort and ● Participated in activities that
the patient will achieve the massage, 30-40 head reduce sympathetic reduce blood pressure or
following: elevation). stimulation. cardiac workload
○ Regular exercise
● Participate in activities that ○ Losing and maintaining
reduce blood pressure or weight at a healthy
cardiac workload 6. Instructed relaxation 6. To reduce stressful level (51kg)
○ Regular exercise techniques. stimuli, produce a
○ Losing and calming effect,
maintaining weight at thereby decreasing ● Engaged in activities that will
a healthy level blood pressure. prevent stress
(45-55 kg) ○ Stress management
○ Balanced activities
○ Rest plan (consistent
sleep-wake hours)
● Engage in activities that will 7. Implemented dietary 7. To help manage fluid
prevent stress sodium, fat and cholesterol retention and ● Incorporated lifestyle changes
○ Stress management restrictions. decrease myocardial
○ Balanced activities workload with the ○ Healthy diet
○ Rest plan (consistent associated ○ Regular exercise
sleep-wake hours) hypertensive
response. Thus, the goal was met.
● Incorporate lifestyle
changes such as healthy
diet and regular exercise 8. Evaluated the 8. To know possible
effectiveness of side effects the
anti-hypertensive drugs as patient may
indicated and observe for experience as drugs
any signs and symptoms are absorbed and
or side effects. metabolized
differently.

9. Documented patient’s 9. To help determine

response to nursing the effectiveness of
management. interventions done
for patient comfort.

10. Advised the patient or her 10. To help to determine

relatives on how to take if the existing
and monitor proper levels treatment plan is
of blood pressure. working.

11. Educated the patient on 11. To promote and

the need and how to sustain an active
incorporate lifestyle and healthy lifestyle
changes. and changes for
improved overall
health.

Dependent:

1. Administered 1. To decrease blood

anti-hypertensive drug as pressure.
ordered.