DE RAMOS, Karen R.

07-12-10
BSN III –A1 / Group CA1
MCP – OR
Ma’am Nenita Orobia

Nursing Care Plan

Priority Problem for severe Hypertension

Cues Nursing Rationale Goals and Nursing Rationale Evaluation

Diagnosis Objectives Intervention
Subjective: Activity Insufficient After 8 hours Independent: After 8 hours
… as verbalized intolerance physiological or of nursing  Assess the  The stated of nursing
by the patient. related to psychological intervention, client’s parameters are intervention,
generalized energy to the patient response to helpful in assessing the patient
Objective: weakness; endure or will be able to activity, responses to the was able to
 verbal report imbalance complete participate in noting pulse stress of activity participate in
of fatigue between required or necessary/ rate more and, if present, are necessary/
and oxygen desired daily desired than 20 beats/ indicators of desired
weakness supply and activities. activities; minute faster overexertion. activities;
 abnormal demand as report a than resting report a
heart rate or evidenced measurable rate; marked measurable
blood by verbal increase in increase blood increase in
pressure report of activity pressure activity
response to fatigue and intolerance; during or after intolerance;
activity weakness; demonstrate activity; demonstrate
 exertional abnormal a decrease in dyspnea or a decrease in
discomfort heart rate Reference: physiologic chest pain; physiologic
or dyspnea or blood page 70 signs of excessive signs of
 ECG changes pressure Nurse’s Pocket intolerance. fatigue and intolerance.
reflecting response to Guide weakness;
ischemia activity; Diagnoses, diaphoresis;
exertional prioritized dizziness or  Energy-saving
 dysrhythmia
discomfort interventions syncope. techniques reduce
s
or dyspnea; and rationale the energy
ECG 11th edition by  Instruct client expenditure, thereby
changes Doenges, in energy- assisting in
reflecting Moorhouse and conserving equalization of
ischemia; Murr techniques; oxygen supply and
dysrhythmi eg., using demand.
as chair when
showering,
sitting to
brush teeth or
combing hair,
carrying out
activities in  Gradual activity
slower pace. progression prevents
a sudden increase in
cardiac workload.
 Encourage Providing assistance
progressive only as needed
activity/ self- encourages
care when independence in
tolerated. performing
Provide activities.
assistance as
needed.

Reference:
Page 41
Nursing Care Plan
Guidelines for
individualizing client
care across the life span
Edition 7 by Doenges,
Moorhouse and Murr