ASSESSMENT

DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: di na ko masyadong makatulong dito sa bahay kasi mabilis akong mapagod

Activity intolerance related to body weakness secondary to underlying disease process

Disease process

Short Term: After 2-3 hours of nursing intervention the patient will identify negative factors affecting

Independent: y Ascertain ability to stand and move about and degree of assistance necessary y To determine current status and needs associated with desired activities To conserve energy and avoid fatigue

After 3 hours of nursing interventions the patient identified negative factors affecting activity intolerance and how to reduce their effects. y To prevent overexertion

Body needs increased effort for systemic circulation

Objectives: Weak in appearance BP 150/90

Increased energy used in response to the increased workload needed

activity intolerance and how to reduce their effects when possible y

Identify and prioritize activities needed Reduce intensity level or encourage to discontinue activities that cause undesired physiological changes

Lack of energy for other physical activities

Long Term: The patient will use identified techniques to enhance

activity Activity Intolerance tolerance

Increase activity/ exercise gradually Teach methods to conserve energy

y y y

To prevent overexertion

To assist client to deal with contributing factors

Balance rest periods with activities Provide brief information about the patients current condition and how to avoid exacerbating or worsening the condition

To prevent fatigue

To provide knowledge to patient and encourage to avoid sedentary lifestyle that will worsen his condition

ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

PLANNING

NURSING INTERVENTION

RATIONALE

EVALUATION

Subjective: Para saan ba yung gamot ko?!

Knowledge deficit r/t chronic disease management

Inherited disease

After 30 mins of nursing care, the patient will verbalize

Monitor clients vital signs, especially BP Define and state the units of desired BP Assist the patient in identifying modifiable risk factors like diet Reinforce the

For baseline parameter Provides basis for understanding elevations of BP This may have been shown to contribute to hypertension To avoid failure of compliance to his antihypertensive therapy Caffeine is a cardiac stimulant and may adversely affect cardiac function

After 30 mins of nursing care, the patient verbalized understanding of the disease and the management to be done.

Age Objective: misunderstanding of the cause and treatment of the disease -confused -denial lack of information about the disease Unhealthy lifestyle Prolonged HPN

understanding of the disease and the management that can be done.

importance of treatment regimen and keeping follow up appointments

Knowledge deficit r/t chronic disease management

Encourage patient to decrease or eliminate caffeine like tea, coffee, cola and

chocolates Stress importance of accomplishing daily rest periods Provide information regarding community resources and support programs in making lifestyle changes Instruct the patient or the significant others on how to take blood pressure Tell the patient and family to keep a record of drugs used in the past Suggest To determine and evaluate the medication being used To have a To monitor clients BP Community resources like health center programs and check ups are helpful in monitoring BP To promote adequate rest

establishing a daily routine for

timely therapeutic

taking medication regimen Instruct the client or the significant others to take his BP at the same hour everyday To monitor clients condition

ASSESSMENT Subjective: Hindi ko mapigilan ang paninigarilyo ko.

NURSING DIAGNOSIS Ineffective Health Maintenance related to Inability to modify lifestyle

INFERENCE Patient was smoking since he was 17yrs. Old Patient is hypertensive Patient wasnt able to stop smoking and drinking alcoholic beverages. Inability to modify lifestyle

PLANNING After 2 hours of nursing interventions the patient will learn and verbalize understanding of factors contributing to current situation.

Objective: (+) Smoker (+) alcohol drinker B.P.: 150/90

This can help the client to learn more about what causes hypertension. Evaluate client Affects for substance use. clients desire/ability to help self. Note setting To note where the client individual lives. adaptation needs. Assess clients To know if desire to learn the client is about his health. eager to help himself. Help the client to Healthy choose a healthy lifestyle lifestyle. measures, such as exercising regularly, maintaining a healthy weight, not smoking, and limiting alcohol intake, help

NURSING INTERVENTIONS Identify and teach the client of the factors that contributes to hypertension.

RATIONALE

EVALUATION After 2 hours of nursing interventions the patient learned and verbalizes understanding of factors contributing to current situation.

 Discuss with client realistic goals for changes in health maintenance.

reduce the risk of being hypertensive and other diseases.

ASSESSMENT Subjective: Madalas akong mahilo,as verbalized by the patient.

Objectives: (+) dizziness (+) headache B.P.: 150/90

NURSING DIAGNOSIS Decreased Cardiac Output related to increased vascular resistance Secondary to Hypertension

INFERENCE Hypertension

PLANNING Short-term:

NURSING INTERVENTIONS Independent: y Evaluate quality and equality of pulses, as indicated.

RATIONALE

EVALUATION Short-term: After 6 hrs of nursing interventions, the client will have no elevation in blood pressure above normal limits and will maintain blood pressure within acceptable limits Long-term: After 5 days of nursing interventions, the client maintained adequate cardiac output as evidenced by absence of signs and symptoms.

After 6 hrs of nursing Decrease circumference of interventions, the arterial the client will have lumen no elevation in blood pressure above normal limits and will Increase maintain systemic blood pressure vascular within resistance acceptable limits Reduced ability of the heart to pump effectively Long-term:

After 5 days of nursing interventions, Inadequate blood the client will maintain pumped by the adequate cardiac heart to meet output. the metabolic demands of the body Decreased Cardiac Output

-Decreased cardiac output results in diminished weak/thread pulses which suggest dysrhytmias. Auscultate -To indicate heart sounds disturbances for presence of normal of murmurs. blood flow within the heart. Monitor -Heart rate heart rate and rhythm and rhythm. respond to medication, activity and developing complications. Note -Overexertion response to increases oxygen activity and promote rest consumption/d emand and can period appropriately compromise myocardial

function. Dependent: y Administer supplemental oxygen as indicated. To increase amount of oxygen available for myocardial uptake, reducing ischemia.

Collaborative: y Review serial ECGs

To provide information regarding. progression/ resolution ofinfarction, status of ventricular function and effects of drug therapies. Monitor To identify laboratory causative/cont data (cardiac ributing enzymes, factors ABgs,electro lytes)

Refer to nutritionist to provide small/easily digested meals. Limit caffeine Intake (coffee, chocolate, cola, as indicated)

Large meals may increase myocardial workload. Caffeine is direct cardiac stimulant that can increase heart rate.

ASSESSMENT

NURSING DIAGNOSIS

INFERENCE

PLANNING

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Subjective: Nag-aalala ako pag iniisip ko ang sakit ko. As verbalized by the patient. Objective: y y y Restless Irritable BP: 150/90

Mild anxiety related to present condition

Disease process

After 1 hour of nursing health education/teaching to the patient and

-identify patients perception of the threat represented by the situation -Determine current prescribed medications and recent drug history of prescribed or OTC medications -monitor physical responses: VS,

-to assess level of anxiety

-after nursing health teaching the patient understands

Increase stress perception

family members/ significant others, the client will diminish and will be relieve from

-These medications can heighten feelings/sense of anxiety

the purpose of the education and willing to do the interventions.

Unfamiliar condition about patients health

anxiety

-to identify physical responses associated with both medical and emotional conditions.

Perceived threat to health

palpitations, rapid pulse, repetitive movements, pacing.

Resulting to mild anxiety -be aware of defense

-that

mechanism being used. may be denial, regression and so forth and encourage patient to acknowledge and to express feelings. -provide accurate information about the situation. Help patient to identify what is reality based. -be available to patient for listening and talking. -review happenings, thoughts and feelings preceding the anxiety attack.

interfere with ability to deal with problem.

-to build rapport and trust.

-to help patient relieve anxiety

-to help patient relieve anxiety

ASSESSMENT

NURSING DIAGNOSIS Imbalance nutrition: less than body requirements r/t lack of information

INFERENCE

PLANNING

NURSING INTERVENTIONS y Ascertain understanding of individual nutritional needs Note availability/ use of financial resources and support systems

RATIONALE

EVALUATION

Subjective: Objective: -weight: 51kg -BMI: 17.6 (underweight) Normal: 20-25 -(+) fatigue -(+) dizziness

After 1 hour of nursing intervention, the client and Unhealthy significant lifestyle others will able to demonstrate Lack of behaviors, knowledge of lifestyle eating changes to healthy regain foods and/or maintain appropriate weight Imbalance nutrition: less than body requirements

Lack of information

To determine information needs of client/SO

Asses weight; To establish baseline measure/calcul parameters ate body fat and muscle mass via triceps skin fold and midarm muscle circumference or other anthropometric measurements

After 1 hour of nursing intervention, the client and significant others was able to demonstrate behaviors, lifestyle changes to regain and/or maintain appropriate weight

Note age,body build, strength, activity/rest level, etc. Use flavoring agents

Helps determine nutritional needs

To enhance food satisfaction and stimulate appetite For initiation/supervision of home nutrition therapy when used

Refer to home health resources

Intervention Plan Health Problem Family Nursing Problem Inability to provide sufficient supply for the medication. Insufficient money to sustain the need for drug maintenance. Goal of Care Objectives of Care After nursing intervention the family will: have adequate knowledge or ideas on how they will be able to find source of income. be able to determine the risk of noncompliance to medication. be able to comply for the medication regimen. Nursing Interventions Discuss the nature, signs, symptoms and complications that might arise due to noncompliance to the medication. Provide information and help the family to know where and how to find source of income. Encourage the family to join community activities or programs that will help provide extra income. Provide sufficient financial support for the medication. Method of Nurse-Family Contact Home Visit Resources Required Human resources: Time and effort on the part of the student nurse and family Financial resources: Money for the student nurse transportation

Noncompliance to medication regimen as a health deficit

After nursing intervention the patient and the family will take the necessary measures to manage and control the proper compliance to the medication.

 Provide knowledge about the benefits of complying the medication and its risks if not.

Intervention Plan Health Problem Family Nursing Problem Inability to provide sufficient supply for the medication. Insufficient money to sustain the need for drug maintenance. Goal of Care Objectives of Care After nursing intervention the family will: have adequate knowledge or ideas on how they will be able to find source of income. be able to determine the risk of noncompliance to medication. be able to comply for the medication regimen. Nursing Interventions Discuss the nature, signs, symptoms and complications that might arise due to noncompliance to the medication. Provide information and help the family to know where and how to find source of income. Encourage the family to join community activities or programs that will help provide extra income. Provide sufficient financial support for the medication. Method of Nurse-Family Contact Home Visit Resources Required Human resources: Time and effort on the part of the student nurse and family Financial resources: Money for the student nurse transportation

Noncompliance to medication regimen as a health deficit

After nursing intervention the patient and the family will take the necessary measures to manage and control the proper compliance to the medication.

 Provide knowledge about the benefits of complying the medication and its risks if not.

Intervention Plan Health Problem Family Nursing Problem Inability to make decisions with respect to taking appropriate health actions due to lack of adequate knowledge in the nature of the health problem. Goal of Care Objectives of Care After nursing intervention the family will: have adequate knowledge about proper nutrition that will help reduce hypertension. be able to determine the risk factors that contribute to hypertension practice proper lifestyle with regards to nutrition and physical fitness. Nursing Interventions Discuss the nature, signs, symptoms and complications that might arise due to hypertension. Discuss with the family the risk factors of hypertension such as family history, age, salt and alcohol intake and obesity. Promote a healthy lifestyle such as encouraging proper food intake like reduced salt and fatty foods. Imply the importance of having an exercise. Discuss ways Method of Nurse-Family Contact Home Visit Resources Required Time and effort on the part of the student nurse and family

Hypertension

After nursing intervention the family will take the necessary measures to properly manage, control and lessen the risk factors of hypertension.

in Smoking cessation. Deliberate that tobacco or nicotine promotes atherosclerosis that may contribute to hypertension. Encourage check-ups and provide referral with a medical practitioner to lessen hypertension and modify risk-factors.

Intervention Plan Health Problem Family Nursing Problem Goal of Care Objectives of Care After nursing intervention the family will: Correct wrong notions about the cause of hypertension. Recognize beginning cases of hypertension and apply preventive/ therapeutic measures. Nursing Interventions Discuss the nature, signs, symptoms and complications of hypertension if proper management is not done. Explore with the family ways of implementing measures to maintain proper management and prevention of hypertension. Method of Nurse-Family Contact Home Visit Resources Required Human resources: Time and effort on the part of the student nurse and family Financial resources: Money for the student nurse transportation

Hypertension as a health threat to the rest of the family

1. Inability to managed hypertension due to lack of knowledge about the condition. 2. Inability to make decisions with respect to taking appropriate health action on the health threat due to failure to comprehend to the nature of the problem. 3. Inability to provide a home environ-ment conducive to health maintenance due to: a. Ignorance of preventive measures b. Inadequate family resources specifically

After nursing intervention, the possibility of uncontrolled hypertension will be minimized or prevented.

financial rsources