Nursing Diagnosis Patient Outcomes Nursing Interventions Nursing Interventions Nursing Interventions

Nursing Diagnosis: Outcome Identification: Please refer to the Patient

Nursing Care Plan for Outcomes tab
Risk for decreased cardiac  The patient will Independent: Hypertension
output related to increased participate in  
vascular vasoconstriction activities that 1. Monitor blood 1. Bounding carotid,
reduce cardiac pressure jugular, radial,
Assessment: workload by periodically. femoral pulses may
04/18/12. Measure both arms be observed/
Subjective Data: “I do not  The patient will three times; 3-5 palpated. Pulses in
really feel well, right now. maintain blood mins apart while the leg may be
My blood pressure is pressure within patient is at rest for diminished,
always high and I feel light acceptable range by initial evaluation. implicating effects
headed when I suddenly 04/19/12. 2. Note presence of, of vasoconstriction
move.” as claimed by  The patient will quality of central and venous
patient. demonstrate stable and peripheral congestion.
cardiac rhythm and pulses. 2. S3 and S4 heart
Objective Data: rate within patient’s 3. Auscultate heart sounds may indicate
normal range by tones and breath atrial and venous
-Pale in color 04/19/12. sounds hypertrophy and
4. Observe skin color, impaired
-Skin cool and moist to   moisture, functioning.
touch temperature and 3. Presence of
  capillary refill time. adventitious breath
-Jugular vein can be easily 5. Note independent or sounds may indicate
seen and bounding upon general edema pulmonary
palpation 6. Provide a calm congestion
environment; secondary to
-Verbalized light minimizing noise; developing heart
headedness on sudden limiting visitors and failure.
change of position length of stay. 4. Presence of pallor;
7. Maintain activity cool and moist skin
-Easy fatigability and restrictions (bed and delayed
occasional dyspnic rest) and assist capillary refill may
occurrences upon exertion patient with self- be due to peripheral
care activities. vasoconstriction or
8. Provide comfort decreased cardiac

-Blood pressure ranging
from 140/90 to 150/100
mmHg, BP as of 6:00 A.M.
04/17/12 is 150/90 mmHg
-Pulse rate of 110 beats per
minute as of 6:00 A.M.
04/17/12
-Capillary refill of 2-3
seconds
Depedent
Collaborative
measures, i.e. output.
elevation of head 5. It may indicate heart
9. Encourage failure, vascular or
relaxation renal impairment.
techniques like 6. Promotes
guided imagery and relaxation.
distractions 7. It reduces physical
10. Monitor response to stress and stimuli
medications to that affect the blood
control blood pressure.
pressure 8. Decreases
discomfort and may
reduce sympathetic
stimulation
11. Administer 9. It helps reduce
medications like stressful stimuli,
diuretics, alpha and thereby decreases
beta antagonists, blood pressure.
calcium channel 10. Response to drug is
blockers, and dependent on both
vasodilators. the individual and
the synergistic
effect of the drug. It
is also important to
12. Instruct and check for any
implement to patient untoward signs and
dietary restrictions symptoms of the
in sodium, fat and medications.
cholesterol 11. These medications
should be medically
prescribed by the
physician and dose
and timing of
medications should
be followed.
Checking BP prior
to giving of
 medications is
always a must to
prevent
hypotension.
12. This restrictions
help manage fluid
retention and
decrease myocardial
workload.