Name of Patient: Mrs.

Allen Age: 70 year-old

Diagnosis: Dementia Sex: Female
Date/Shift Assessment Need Nursing Plan of care Nursing Interventions and Evaluation
Diagnoses Rationale

October Subjective: Health Readiness for   Review clients at risk as  Measure BP in both At the end of the
2021 Perception- enhanced noted in Related Factors arms. Take three treatment regimen,
“My
Health health and individuals with readings 3 to 5 the following are
daughter is
Management management conditions that stress minutes apart while expected to be
worried
Pattern the heart. client is at rest then achieved:
about my Scientific
  Check laboratory data sitting and then
health, me basis:
(cardiac markers, standing for initial  Maintain blood
not sleeping
A pattern of complete blood cell evaluation. Use pressure at
...I am
regulating count, electrolytes, ABGs correct cuff size and less than
taking care
and , blood urea nitrogen accurate technique. 140/90
of my
integrating and creatinine, cardiac Take note of mmHg with
husband
into daily enzymes, and cultures, elevations in systolic lifestyle
who has
living a such as blood, wound, or as well as diastolic modifications,
dementia
therapeutic secretions). readings. medications,
and his
regimen for  Monitor and record BP. Rationale: Serial or both.
nurse is also
treatment of Measure in both arms measurements using  Demonstrate
worried
illness and its and thighs three times, correct equipment no symptoms
about my
sequelae, 3–5 minutes provide a more of angina,
blood
which can be complete picture of palpitations, or
pressure
strengthened. vascular visual changes.
creeping
involvement and  Has stable
up.”
scope of problem. BUN and
Objective:  Note presence, serum
quality of central creatinine
BP: 148/86 and peripheral levels.
mmHg pulses.  Has palpable
(sitting) and Rationale: Bounding peripheral
146/82 carotid, jugular, pulses.
mmHg radial, and femoral  Adheres to the
(standing) pulses may be dietary
observed and regimen as
HR: 90
palpated. Pulses in prescribed.
strong, the legs and feet  Exercises
regular, may be diminished, regularly.
with a knee reflecting effects of  Takes
pain level of vasoconstriction medications as
2/10 (increased systemic prescribed and
vascular resistance reports side
[SVR]) and venous effects.
congestion.  Measures
 Auscultate heart blood pressure
tones and breath routinely.
sounds.  Abstains from
Rationale: S4 heart tobacco and
sound is common in alcohol intake.
severely  Exhibits no
hypertensive complications.
patients because of
atrial hypertrophy
(increased atrial
volume and
pressure).
Development of
S3 indicates
ventricular
hypertrophy and
impaired
 functioning. The
presence of crackles,
wheezes may
indicate pulmonary
congestion
secondary to
developing or
chronic heart failure.
 Observe skin color,
moisture,
temperature, and
capillary refill time.
Rationale: The
presence of pallor;
cool, moist skin; and
delayed capillary
refill time may be
due to peripheral
vasoconstriction or
reflect cardiac
decompensation
and decreased
output.
 Note dependent
and general edema.
Rationale: May
indicate heart
failure, renal or
vascular
impairment.
 Provide calm, restful
surroundings,
minimize
environmental
activity and noise.
Consider limiting the
number of visitors
or length of
visitation.
Rationale: Helps
reduce sympathetic
stimulation and
promotes relaxation.
 Maintain activity
restrictions (such as
bedrest or chair
rest) during crisis
situation and
schedule periods of
uninterrupted rest;
assist client with
self-care activities as
needed.
Rationale: Reduces
physical stress and
tension that affect
BP and the course of
hypertension.
 Provide comforts
measures, such as
back and neck
 massage or
elevation of head.
Rationale:
Decreases
discomfort and may
reduce sympathetic
stimulation.
 Instruct in relaxation
techniques, guided
imagery, and
distractions, if client
is interested and
able to participate.
Rationale: Can
reduce stressful
stimuli and produce
calming effect,
thereby reducing BP.
 Monitor response to
medications that
control BP.
Rationale: Response
to drug therapy is
dependent on both
the individual drugs
and their synergistic
effects. Because of
potential side effects
and drug
interactions, it is
important to use the
smallest number
and lowest dosage
of medications
possible.