Assessment Nursing Diagnosis Planning Interventions Evaluations

SUBJECTIVE:
“nahihilo ako tapos Decreased cardiac output After 8 hours of nursing Encourage and maintain After 8 hours of nursing
lumalabo paningin ko and related to increased interventions, the patient bed rest during acute intervention the patient was
sumisikip din dibdib ko” as peripheral vascular will be able to verbalize an phase. able to stabilize her blood
verbalize by the patient resistance secondary to absent of dizziness, blurred - Minimizes stimulation pressure evidenced by
hypertension as evidence vision and chest pain and and promotes relaxation. 120/80 bp and dizziness,
OBJECTIVE: by BP of 154/86, patient BP will be stabilized to blurred vision, and chest
-Tachycardia complaining of dizziness, 120/80 ·Assess the patient’s blood pain were relieved.
-Pale in color-Skin cool blurred vision, and chest pressure and cardiac
and moist to touch pain. rhythm every hour until
-Jugular vein can be easily stable.
seen and bounding upon -To monitor if medications
palpation and the dose is having
favorable effect.
Height: 5’4
Weight: 165-185 lbs. ·Assess the patient’s chest
Fatigability pain level and blurred
Palpitation vision every 4 hours until
absent.
Vital signs: -To ensure patient’s
BP: 154/86 safety.
TEMP: 36.0 c
PR: 118 bpm ·Educate the patient on
RR: 15 cpm how to consult with his
doctor before stopping
medication.
Patient has history of: -To prevent rebound
Type 2 diabetes hypertension
Obesity
Hypertension ·Promote adequate rest by
Migraine headache decreasing stimuli and
Mild polyuria & Polydipsia providing quiet
environment.
-For the patient to be
comfortable during the
therapy.

·Provide for restrictive

diet: low salt, low fat diet
Collaborative:
-Salt retains water thus
increasing blood volume
and blood pressure.

Assist patient with

ambulation as needed.
- Dizziness and
blurred vision frequently
are associated with
vascular headache. Patient
may also experience
episodes of
postural hypotension,
causing weakness when
ambulating.

·Administer anti-
hypertensive medications
(e.g. Clonidine), as
prescribed.
-May be given to treat
hypertension.