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 sounds may indicate
seen and bounding upon or 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
 measures, i.e. output.
-Blood pressure ranging elevation of head 5. It may indicate
from 140/90 to 150/100 9. Encourage heart failure,
mmHg, BP as of 6:00 relaxation vascular or renal
A.M. 04/17/12 is 150/90 techniques like impairment.
mmHg guided imagery and 6. Promotes
distractions relaxation.
-Pulse rate of 110 beats per 10. Monitor response to 7. It reduces physical
minute as of 6:00 A.M. medications to stress and stimuli
04/17/12 control blood that affect the blood
pressure pressure.
-Capillary refill of 2-3 8. Decreases
seconds Depedent discomfort and may
reduce sympathetic
11. Administer stimulation
medications like 9. It helps reduce
diuretics, alpha and stressful stimuli,
beta antagonists, thereby decreases
calcium channel blood pressure.
blockers, and 10. Response to drug is
vasodilators. dependent on both
the individual and
Collaborative the synergistic
effect of the drug. It
12. Instruct and is also important to
implement to check for any
patient dietary untoward signs and
restrictions in symptoms of the
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.