QUINDIPAN, RIZALYN A.

BSN III – NCP

September 12, 2020

Pearl Johnson is a 52-year-old African American patient at St. Louis College Nursing Home. Pearl’s past medical history includes uncontrolled hypertension. Pearl has recently
suffered from a stroke that caused dysphasia, hemiplegia, and aphasia. She was just placed in the nursing home and needs complete care. Pearl has a daughter who is 18 years old
and visits every day; her son is 22. He has a lot of difficulty making it to come see his mom. Pearl is divorced and has a mother who is still living and who has health problems due
to obesity and diabetes. Pearl’s mother is unable to care for her daughter at home, because of her own medical issues. She visits frequently and is not compliant with the
physician’s orders. She feels her daughter is still hungry after her tube feeding and gives her food.

This morning, the certified medical technician was attempting to give Pearl her medication and noted that the patient’s blood pressure was quite elevated. Her blood pressure was
192/120 mm Hg, her temperature 98.6°F. She gets continuous tube feedings at 30 mL/h.

Reference:
Gulanick, Meg. “Nursing Care Plans: Nursing Diagnosis and Intervention.” Apple Books.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (Edition 14.). Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins.
QUINDIPAN, RIZALYN A.
BSN III – NCP
ACTUAL
ASSESSMENT EXPLANATION OF THE PLANNING INTERVENTION RATIONALE EVALUATION
PROBLEM
“Bigla nalang po siyang Inadequate blood pumped by Within 3 hour of nursing - Monitor vital signs - To determine present Within 3 hour of nursing
nanghina” verbalized by the the heart to meet the intervention the patient will: especially the blood condition of the intervention the patient was
mother metabolic demands of the - Decrease blood pressure, respiratory patient able to:
body. Common causes of pressure from rate, and pulse rate - Decrease blood
Objective: reduced cardiac output 192/120 mmHg to - Assess patient’s - Cold, pale and pressure from
- Insufficient include myocardial infarction, 160/100 mmHg condition like clammy skin is 192/120 mmHg to
knowledge about hypertension, valvular heart - Put in comfortable capillary refill, skin secondary to 160/100 mmHg
current condition disease, congenital heart position color, temperature, compensatory - Put in comfortable
- Suspended in bed due disease, cardiomyopathy, and moisture increase in position
to paralysis of one pulmonary disease, Within 2 days of nursing sympathetic nervous
side of the body arrhythmias, drug effects, intervention the patient will: system stimulation Within 2 days of nursing
- Slurred speech fluid overload, decreased - Have gradual and low cardiac intervention the patient was
- Unmotivated fluid volume, and electrolyte decrease of blood output. Capillary able to:
- Looking frail and imbalance. Older patients are pressure refill is slow, - Have gradual
pale especially at risk because the - Skin dry and warm to sometimes absent decrease of blood
- Dyspnea aging process causes reduced touch pressure
- Cold clammy skin compliance of the ventricles, - Have Good capillary - Assess oxygen - Change in oxygen - Skin dry and warm to
- Poor capillary refill which further reduces refill saturation using pulse saturation is one of touch
- Looks uncomfortable contractility and cardiac - Be in comfortable oximeter the earliest indicators - Have Good capillary
Vital signs taken: output. Patients may have position of reduced cardiac refill
BP – 192/180 mmHg acute, temporary problems or - Reduce use of output - Be in comfortable
HR – 60 bpm experience chronic, accessory muscle - Raise side rails of the position
RR – 16 cpm SPO2 – 93 % debilitating effects of patient’s bedside - Safety of the patient - Reduce use of
T – 37 c decreased cardiac output. accessory muscle
Nursing Diagnosis: Patients may be managed in - Administer oxygen - To help in oxygen –
Decreased cardiac output an acute care, ambulatory carbon dioxide
related to increased peripheral care, or home care setting.” exchange
vascular resistance secondary - Position in high
to hypertension as evidence fowler’s - To facilitate lung
by elevated blood pressure. expansion
- Administer
medication as - Depending on
Reference:
Gulanick, Meg. “Nursing Care Plans: Nursing Diagnosis and Intervention.” Apple Books.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (Edition 14.). Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins.
QUINDIPAN, RIZALYN A.
BSN III – NCP
directed by the etiological factors,
physician such as common medication
beta – adrenergic such as digitalis,
agents diuretics, vasodilator
therapy,
antidysrrhythmics,
angiotensin
converting enzyme
inhibitors, and
- ECG monitoring as inotropic agents.
ordered by the
physician - Cardiac dysrhythmias
may occur from low
perfusion, acidosis or
hypoxia. Older
patients are
especially sensitive to
the loss of atrial kick
in atrial fibrililation.
- Monitor
hemodynamic - Close monitoring of
parameters at these parameters
prescribed level guides titration of
fluids and
medication.
- Explain symptoms
and interventions for - Though
decreased cardiac understanding for of
output related to specific causes for
etiological factors each patient’s disease
is necessary for
appropriate follow
through of treatment
plan
- Explain the drug
Reference:
Gulanick, Meg. “Nursing Care Plans: Nursing Diagnosis and Intervention.” Apple Books.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (Edition 14.). Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins.
QUINDIPAN, RIZALYN A.
BSN III – NCP
regimen, purpose, - Information provides
dose, and side effects rationale for therapy
and aids the patient in
assuming
responsibility for self
care later.

- Explain diet - Diet changes and

restrictions for restrictions can be
example, with respect especially
to fluid and sodium challenging to
intake patients and may
require ongoing
monitoring

POTENTIAL
ASSESSMENT EXPLANATION OF THE PLANNING INTERVENTION RATIONALE EVALUATION
Reference:
Gulanick, Meg. “Nursing Care Plans: Nursing Diagnosis and Intervention.” Apple Books.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (Edition 14.). Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins.
QUINDIPAN, RIZALYN A.
BSN III – NCP
“Paralyze po iyong half ng
body niya. Hindi din po siya
makapagsalita ng maayos.”
Verbalized by the mother
Objective:
- Insufficient
knowledge about
current condition
- Suspended in bed due
to paralysis of one
side of the body
- Slurred speech
- Unmotivated
- Looking frail and
pale
- Dyspnea
- Cold clammy skin
- Poor capillary refill
- Looks uncomfortable
Vital signs taken:
BP – 192/180 mmHg
HR – 60 bpm
RR – 16 cpm SPO2 – 93 %
T – 37 c
Nursing Diagnosis:
Impaired physical mobility
related to neuromuscular
impairment as evidence by
impaired coordination,
inability to do activities of
daily living, and decreased
muscle strength and control
Reference:
Gulanick, Meg. “Nursing Care Plans: Nursing Diagnosis and Intervention.” Apple Books.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (Edition 14.). Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins.
PROBLEM
Limitation in independent,
purposeful physical
movement of the body or of
one or more extremities
Alteration in mobility may be
a temporary or more
permanent problem. Most
disease and rehabilitative
states involve some degree of
immobility (e.g., as seen in
strokes, leg fracture, trauma,
morbid obesity, multiple
sclerosis). With the longer
life expectancy for most
Americans, the incidence of
disease and disability
continues to grow. With
shorter hospital stays, patients
are being transferred to
rehabilitation facilities or sent
home for physical therapy in
the home environment.
Mobility is also related to
body changes from aging.
Loss of muscle mass,
reduction in muscle strength
and function, stiffer and less
mobile joints, and gait
changes affecting balance can
significantly compromise the
mobility of older patients.
Mobility is paramount if
older patients are to maintain
any independent living.
Within 4 hours of nursing - Assess for - Identifying barriers to Within 4 hours of nursing
intervention the patient will: impediments of mobility guides intervention the patient was
- Maintain skin mobility design of an optimal able to:
integrity care plan - Maintain skin
- Maintain optimal - Assess extent of - Identifies strengths integrity
position of function impairment initially and deficiencies that - Maintain optimal
and on a regular basis may provide position of function
Within 2 days of nursing information regarding
intervention, the patient will: recovery Within 2 days of nursing
- Demonstrate increase - Observe affected side - Edematous tissue is intervention, the patient was
strength and function for color, edema, or more easily able to:
of affected or other signs of traumatized and heals - Demonstrate increase
compensatory body compromised slowly strength and function
part circulation of affected or
- Will demonstrate - Change position at - Reduces risk of tissue compensatory body
techniques and least every 2 hours injury. Affected side part
behaviors that enable (side lying and has poorer circulation - Demonstrate
resumption of supine) and possibly and reduced techniques and
activities more often if placed sensation and is more behaviors that enable
on affected side predisposed to skin resumption of
breakdown activities
- Position in prone
position once or - Help maintain
twice a day if patient functional hip
can tolerate extension; however,
may increase anxiety,
especially about
ability to breathe
- Elevate arm and hand - Promotes venous
return and helps
prevent edema
formation
QUINDIPAN, RIZALYN A.
BSN III – NCP
Restricted movement affects
the performance of most - Encourage patient to - May respond if
ADLs. Older patients are also assist with movement affected side is no
at increased risk for the and exercises using longer part of the
complications of immobility. unaffected extremity body and needs
to support and move encouragement and
weaker side active training to
reincorporate it as a
part of own body.

FDAR CHART

09/12/2020 FOCUS – Elevated Blood Pressure

Reference:
Gulanick, Meg. “Nursing Care Plans: Nursing Diagnosis and Intervention.” Apple Books.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (Edition 14.). Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins.
QUINDIPAN, RIZALYN A.
BSN III – NCP
7:OO AM DATA – conscious and not conversant; on a supine position; “Nakakatakot iyong mga ganito na nangyayari sa anak ko” verbalized by the mother;
blood pressure taken is 192/120 mmHg; with slurred speech; use of accessory muscle when breathing; cold, pale and clammy skin; with poor
capillary refill and in a uncomfortable position and immobile on bed.
ACTION – Monitored vital signs especially the blood pressure, respiratory rate, and pulse rate; Assessed patient’s condition like capillary refill,
skin color, temperature, and moisture; Assessed oxygen saturation using pulse oximeter; Raised side rails of the patient’s bedside; Administered
oxygen; Positioned in high fowler’s; Administer medication as directed by the physician such as beta – adrenergic agents; monitored ECG as
ordered by the physician; Monitored hemodynamic parameters at prescribed level; Explained symptoms and interventions for decreased cardiac
output related to etiological factors; educated them about the drug regimen, purpose, dose, and side effects; Explained diet restrictions for example,
with respect to fluid and sodium intake

3:00 PM RESPONSE – Decreased blood pressure from 192/120 mmHg to 160/100 mmHg.

QUINDIPAN, RIZALYN A.
UB SN -III

DRUG NAME MODE OF ACTION INDICATION SIDE EFFECT NURSING RESPONSIBILITIES

Reference:
Gulanick, Meg. “Nursing Care Plans: Nursing Diagnosis and Intervention.” Apple Books.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (Edition 14.). Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins.
QUINDIPAN, RIZALYN A.
BSN III – NCP
Brand Name: May be related to  HTN
Trandate reduced peripheral Adults (inpatients after IV therapy):  Once
vascular resistance, as a
supine diastolic BP has begun to rise,
Generic Name: result of alpha and beta
give 200 mg PO, followed by 200 to 400
Labetalol hydrochloride blockade. mg PO in 6 to 12 hours depending on BP
response. May increase by 200 mg PO
Classification: b.i.d. at 1-day intervals. Usual dosage
Antihypertensives/Alph range is 100 to 300 mg PO b.i.d.
a – beta blockers
 Severe HTN, hypertensive
emergencies
Dosage:
Adults (inpatients): 200 mg diluted in
300 mg
160 mL of a commonly used IV fluid
infused at 2 mg/minute IV or 200 mg
Frequency:
diluted in 250 mL of a commonly used IV
40-80 mg every 10
fluid and administered at 3 mL/minute IV
minutes
until satisfactory response is obtained;
then infusion is stopped. Maximum dose
Route:
is 300 mg.Or, give by repeated IV
IV
injection; initially, 20 mg IV slowly over
2 minutes. Repeat injections of 40 to 80
mg every 10 minutes until maximum dose
of 300 mg is reached, as needed.
Contraindication:
- Contraindicated in patients
hypersensitive to drug or its
components and in those with
bronchial asthma(history of
obstructive airway disease), overt HF,
greater than first-degree heart block
(except in patients with a functioning
Reference:
Gulanick, Meg. “Nursing Care Plans: Nursing Diagnosis and Intervention.” Apple Books.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (Edition 14.). Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins.
CNS: dizziness, fatigue, headache, pares
thesia, transient scalp
tingling, syncope, vertigo, asthenia,
somnolence.
CV: edema, orthostatic hypotension,
flushing, ventricular arrhythmias.
EENT: nasal congestion.
GI: nausea, vomiting, dyspepsia, taste
distortion.
GU: sexual dysfunction, urine retention.
Respiratory: bronchospasm, dyspnea,  closely because beta
wheezing.
Skin: rash, increased sweating, pruritus.
- Monitor BP frequently.
Drug masks common signs
and symptoms of shock.
- Keep patient supine while
patient is receiving IV
therapy. Monitor BP closely
before allowing patient to
ambulate.
- In diabetic patients,
monitor glucose level
blockers may mask certain
signs and symptoms
of hypoglycemia.
- Don’t routinely withdraw
long-term beta-blocker
therapy before surgery.
- Rare occurrences of severe
hepatic injury have been
reported. Monitor LFTs.
- Advise patient to take drug
in a consistent manner with
regard to meals.
- Advise patient
that dizziness is the most
common adverse reaction
and tends to occur in the
early stages of treatment, in
patients taking diuretics, and
with higher dosages. Inform
patient that dizzinesscan be
minimized by rising slowly
QUINDIPAN, RIZALYN A.
BSN III – NCP
pacemaker), cardiogenic shock, and avoiding sudden
severe bradycardia, and other position changes.
conditions that may cause severe and - Warn patient that
prolonged hypotension. occasional, harmless scalp
- Use cautiously in patients with HF, tingling may occur,
hepatic failure, chronic especially when therapy
bronchitis, emphysema, PVD, begins.
and pheochromocytoma.
- There are no adequate studies in
pregnant women. Use during
pregnancy only if potential benefit
justifies potential risk to the fetus.
- Low amounts of drug appear in
human milk and can be detected in
the serum of breastfeeding infants.
Use cautiously in breastfeeding
women.

Reference:
Gulanick, Meg. “Nursing Care Plans: Nursing Diagnosis and Intervention.” Apple Books.
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (Edition 14.). Philadelphia: Wolters Kluwer Health/Lippincott Williams &
Wilkins.