CUES AND EVIDANCES Subjective: Medyo lipong ko og labad akong ulo.

NURSING DIAGNOSIS Ineffective tissue perfusion related to vasoconstric Objective: tion of Vital signs(11/17/10) blood BP:160/100 vessels PR:84 bpm RR:25 cpm

OBJECTIVES At the end of our care the patient will demonstrate improved perfusion as evidenced by blood pressure within normal range.

INTERVENTIONS Independent

RATIONALE

EVALUATION At the end of our nursing care, client manifested improved condition as evidenced by:

Monitor blood pressure every 4 hours.

-Serve as baseline data for alterations that might need immediate interventions and could serve as a danger sign. -Conserves energy and lowers tissue 02 demands. (Environmental Manipulation theory by Florence Nightingale) -To prevent edema that may activate renin angiotensin-aldosterone system. (According to Hildegard Peplau, nurses must also assume the role of a teacher that imparts knowledge concerning a need or interest.)

-Met. Blood pressure is 120/80 mmhg. (11/19/10; 12 00).

Encourage quiet, restful atmosphere.

-Met. Claimed improved sleep.

Health teaching on sodium-restriction and low fat diet.

-Met. Restated the importance of maintaining low-fat and sodiumrestricted diet.

Dependent: Administer hypertensive as ordered: - Captopril 750 mg q 6H for BP > 160/90

-Blocks ACE from converting Angiotensin I to Angiotensin II, a powerful vasoconstrictor, leading to decreased blood pressure, decreased aldosterone

Enalapril 20 mg 1 tab OD

secretion, a small increase in potassium levels and sodium and fluid loss, involved in the antihypertensive action.

CUES AND EVIDANCES Subjective: Guot akong dughan pagkatulog nako. Objective: Vital signs(11/17/10) BP:160/100 PR:84 bpm RR:25 cpm

NURSING DIAGNOSIS Impaired gas exchange related to lung congestion

OBJECTIVES

INTERVENTIONS

RATIONALE

EVALUATION At the end of our nursing care, client manifested improved condition as evidenced by:

At the end of our Independent: care the patient will demonstrate improved Monitor the ventilation and respiratory rate of oxygenation of patient regularly. tissues as Elevating the head or evidenced by: positioning client Respiratory appropriately in bed. rate within Evaluate pulse normal limits. oximetry to determine RR=15-20 oxygenation cpm. Raising the side rails Absence of of the bed to prevent respiratory falls. distress. Normal 02 and CO2 level. Promote bed rest.

-To evaluate degree of compromise.

-To maintain airway.

-To asess respiratory insufficiency.

-Unmet. Respiratory rate=24 cpm, shallow, regular.(11/19/10; 12 00) -Met. Claimed relief from chest tightness. -Unmet. O2 and C02 level has not been obtained.

-To secure patient in bed and prevent injury, in case the patient gets confused due to hypoxia (reduced oxygen in the brain) Helps limit oxygen needs and regain energy.

Dependent: Administering oxygen as ordered

To increase tissue oxygenation