Nursing Care Plan:

PLANNING
ASSESSMENT NURSING GOAL / EVALUATION
NURSING
DIAGNOSIS EXPECTED RATIONALE
INTERVENTIONS
OUTCOME
Subjective Risk for After 6 hours of INDEPENDENT INDEPENDENT After 6 hours
Data decreased nursing Monitor and Comparison of of nursing
“I have my cardiac output intervention: record BP. pressures provides intervention,
maintenance a complete picture the goal was
medicine, SHORT- of vascular met when the
Losartan.” As
TERM GOALS involvement or the client:
the caregiver
stated - Patient will scope of the
participate in problem. Severe - participated
Objective activities that hypertension is in activities
Data reduce classified in adults that reduce
- dyspnea BP/cardiac as a diastolic BP/cardiac
workload. pressure elevation workload.
of 110 mmHg;
- Patient will progressive - maintained
maintain BP diastolic readings BP within
within above 120 mmHg individually
individually are considered first acceptable
acceptable accelerated, then range.
range. malignant (very
severe). - demonstrated
- Patient will stable cardiac
demonstrate Note presence, Bounding carotid, rhythm and
stable cardiac quality of central jugular, radial, and rate within
rhythm and rate and peripheral femoral pulses may patient’s
within patient’s pulses. be observed and normal range.
normal range. palpated. Pulses in
the legs and feet - participated
- Patient will may be diminished, in activities
participate in reflecting effects of that will
activities that vasoconstriction prevent stress
will prevent (increased systemic (stress
stress (stress vascular resistance management,
management, [SVR]) and venous balanced
balanced congestion. activities and
activities and rest plan).
rest plan). Observe skin The presence of
color, moisture, pallor; cool, moist
temperature, and skin; and delayed
capillary refill capillary refill time
time. may be due to
peripheral
vasoconstriction or
reflect cardiac
decompensation
and decreased
output.

Note dependent May indicate heart

and general failure, renal or
edema. vascular
impairment.

Evaluate client To assess for signs

reports or of poor ventricular
evidence of function or
extreme fatigue,
intolerance for impending cardiac
activity, sudden failure.
or progressive
weight gain,
swelling of
extremities, and
progressive
shortness of
breath.

Provide calm, Promotes

restful relaxation.
surroundings,
minimize
environmental
activity and noise.

Advise activity Lessens physical

restrictions stress and tension
(bedrest or chair that affect blood
rest); schedule pressure and the
uninterrupted rest course of
periods; assist hypertension.
patient with self-
care activities as
needed.

Provide comfort Decreases

measures. discomfort and
may reduce
sympathetic
stimulation.

Implement dietary These restrictions

sodium, fat, and can help manage
cholesterol fluid retention and,
restrictions as with the associated
indicated. hypertensive
response, decrease
myocardial
workload.