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Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
NURSING DIAGNOSIS Infective cerebral tissue perfusion R/T increase peripheral pressure as evidence by elevated blood pressure
PLANNING
INTERVENTION
RATIONALE
EVALUATION
S: Mataas ang BP ko as verbalized by the patient. O: T: 37.5C BP: 170/100 mmHg PR: 81 bpm RR: 20 cpm conscious and coherent weak in appearance
Monitor V/S Advise patient to have adequate rest period Provide comfort measures Provide rest in between activities Advised the patient to use relaxation techniques Discourage sitting and standing for long period of time
Facilitate management of hypertension which is the major risk factor for damage to blood vessels / organ function To prevent fatigue To provide comfort To promote the relaxation of the body for new activities To destruct attention and reduce tension To maximum tissue perfusion
After a series of nursing intervention the patient was manifested BP: 130/90 mmHg