Assessment Diagnosis Outcome Intervention Rationale evaluation

Identification
SUBJECTIVE: Risk for prone After 2 hours of
“mataas ba behavior related After 2 hours of INDEPENDENT: nursing
ang bp ko? Ok to lack of nursing interventions, •Define and state the limits of Provides basis for interventions, the
lng ba ‘yon? knowledge about the patient was able desired BP. Explain understanding elevations patient was able
Minsan kasi the disease. to verbalize hypertension and its effect on of BP, and clarifies to verbalize
napapasarap understanding of the the heart, blood vessels, misconceptions and also understanding of
ang kain ko.” disease process and kidney, and brain. understanding that high the disease
treatment regimen. BP can exist without process and
OBJECTIVE: symptom or even when treatment
•Request for feeling well. regimen.
information.
•Assist the patient in •These risk factors have
•V/S taken as identifying modifiable risk been shown to contribute
follows: factors like diet high in to hypertension.
T: 36.5 sodium, saturated fats and
P: 72 cholesterol.
R: 21
BP: 150/90 •Reinforce the importance of •Lack of cooperation is
adhering to treatment common reason for failure
regimen and keeping follow of antihypertensive
up appointments. therapy.

•Suggest frequent position •Decreases peripheral

changes, leg exercises when venous pooling that may
lying down. be potentiated by
vasodilators and
prolonged sitting or
standing.
•Help patient identify sources •Two years on moderate
of sodium intake. low salt diet may be
 sufficient to control mild
hypertension.

•Encourage patient to •Caffeine is a cardiac

decrease or eliminate stimulant and may
caffeine like in tea, coffee, adversely affect cardiac
cola and chocolates. function.

•Stress importance of •Alternating rest and

accomplishing daily rest activity increases
periods. tolerance to activity
progression.
DEPENDENT:
•Give due medications •Refer to drug study.