CUES

Subjective:
Medyo
nahihilo lang
ako, pero hindi
ko alam kung
bakit. As
verbalized by
the patient.
Objective:
-weakness
-dizziness
-loneliness
-vital sign
taken:
Temp: 36.1
PR: 72
RR: 24
BP: 150/100

DIAGNOSIS
Knowledge
deficient
related to
information
misinterpretati
on.

INFERENCE
Absence or
deficiency of
cognitive
information
related to
specific topic;
lack of specific
information
necessary for
clients to
make
informed
choices
regarding
condition/
treatment/
lifestyle
changes.

PLANNING
Short Term
Goal:
After 1 hour of
nursing
interventions,
the patient will
verbalize
understanding
of the disease
process and
treatment
regimen.
Long Term
Goal:
After 8 hours
of nursing
intervention
the patient
should be
manifest
decrease of BP
from 150/100
to 120/80.

INTERVENTION
1. Define and
state the limits
of desired BP.
Explain
hypertension
and its effect
on the heart,
blood vessels,
kidney, and
brain.

2. Assist the
patient in
identifying
modifiable risk
factors like
diet high in
sodium,
saturated fats
and
cholesterol.
3. Reinforce
the
importance of
adhering to
treatment
regimen and
keeping follow
up
appointments.

RATIONALE
1. Provides
basis for
understanding
elevations of
BP, and
clarifies
misconception
s and also
understanding
that high BP
can exist
without
symptom or
even when
feeding well.
2. These risk
factors have
been shown to
contribute to
hypertension.

3. Lack of
cooperation is
common
reason for
failures of
antihypertensi
ve therapy.
4. Decreases

EVALUATION
Short Term
Goal:
After 1 hour of
nursing
interventions,
the patient
was able to
verbalize
understanding
of the disease
process and
treatment
regimen as
manifested by
decreasing the
BP 150/100.
Long Term
Goal:
After 8 hours
of nursing
intervention
the patient BP
was able to
decrease
130/90.

4. Suggest
frequent
position
changes, leg
exercises
when lying
down.

peripheral
venous
pooling that
may be
potentiated by
vasodilators
and prolonged
sitting and
standing.

5. Help patient
identify
sources of
sodium intake.

5. Two years
on moderate
low salt diet
may be
sufficient to
control mild
hypertension.

6. Stress
importance of
accomplishing
daily rest
periods.

6. Alternating
rest and
activity
increases
tolerance to
activity
progression.

COLLABORATI
VE:
7. Provide
information
regarding
community
resources and
support
patient in

7. Community
resources like
health centers
programs and
check ups are
helpful in
controlling
hypertension.

making
lifestyle
changes.