NURSING CARE PLAN

NAME OF PATIENT: Lota Eugenio WARD: General Ward

DIAGNOSIS: Hypertensive Urgency DATE: December 3, 2020

ASSESSMENT BACKGROUND NURSING OBJECTIVES NURSING RATIONALE EVALUATION

KNOWLEDGE DIAGNOSIS INTERVENTION
Subjective Data: Independent:
- Patient’s Hypertensive Activity - address - Measure in both - Comparison of - steady or
daughter reports, crisis is an Intolerance negative factors arms/thighs three times, pressures provides a gradual decrease
severe headache umbrella term RT affecting activity 3–5 min apart while more complete picture in blood pressure
and neck pain, for hypertensive Generalized intolerance, patient is at rest, then of vascular is recorded as
accompanied by urgency and Weakness namely sitting, then standing for involvement/scope of well as increase
confusion and hypertensive Secondary to maintaining initial evaluation. Use problem.This provides a in O2 saturation
blurred vision prior emergency Hypertensiv blood pressure correct cuff size and comparative baseline within normal
to admission wherein blood e Crisis within accurate technique and information about parameters
pressure spikes individually needed education or within the shift
Objective Data: up to 180/120 acceptable range interventions regarding __ met
- Vital signs that or higher. The and stable quality of life __ unmet
reveal the main difference cardiac rhythm __ partially met
following: between the and rate within - Determine clients - this provides a
BP: 180/120 two is that if patient’s current activity level and baseline for comparison - A decrease in
O2 sat: 94% organ damage is acceptable physical condition with and an opportunity to Wong baker’s
- Wong Baker’s present or not. parameters observation exercise- track changes pain rating scale
pain rating scale Either way, both within the shift capacity testing or use of to at least 5/10
score of 8/10 conditions result a functional level and client reports
- nurse observes with the heart - Patient and/or classification such as increase in
patient in a not being able family will report Gordon’s as appropriate comfort.
generally to pump blood measurable __ met
weakened state effectively, increase in - Assist with activities __ unmet
resulting in activity tolerance and provide or monitor - to protect client from __ partially met
generalized within a clients use of assistive injury
weakness and measurable time devices such as crutches, - nurse is able to
other symptoms frame walker, or wheelchair collaborate and
such as formulate an
headache Dependent: activity plan for
accompanied by - administer the client that
confusion and antihypertensive or - reduces blood they would want
blurred vision, analgesic medications as pressure and increases to adhere to
shortness of ordered tissue perfusion which within the shift
breath, anxiety, alleviates weakened __ met
and severe state __ unmet
chest pain. This __ partially met
condition can - Maintain activity - Reduces physical
lead to activity restrictions, e.g., stress and tension that - Demonstrate an
intolerance bedrest/chair rest; affect blood pressure increased
wherein there is schedule periods of and the course of tolerance in at
insufficient uninterrupted rest; assist hypertension. least 1 activity
physiological or patient with self-care within the shift
psychological activities as needed. __ met
energy to __ unmet
endure various Collaborative: __ partially met
activities. - Plan activities that can - Planning of activities
be used for exercise- can be used measure
capacity testing. Increase client activity tolerance
exercise or activity levels while promoting
gradually. teach methods recovery. Reducing
to conserve energy such intensity level prevents
 as stopping to rest for overexertion, and
three minutes during a involving patient or
10 minute walk or sitting significant other in plan
down to brush hair of activities promotes
instead of standing. adherence.
Involve client and family
in planning activities as
much as possible

- instruct patient and - minimizes patient’s

family about limits and risk for unwanted
risks of current state physical exertion and
such as overexertion or injuries
risk for falls. Promote
providing assistance.

NAME OF STUDENT: Jenny Juniora Ajoc CLINICAL INSTRUCTOR: Prof. Alvin Imperio
BLOCK & YEAR: BSN 210