ASSESSMENT NURSING SCIENTIFIC BACKGROUND PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Risk for Stimulation of vasomotor Short Term Goal: Independent: Independent: Short Term Goal:
Decrease center (loc in medulla) send
“Nakaramdam ako ng Cardiac Output impulses to CNS After 8 hours of - Establish  To build a After 8 hours of
hilo at pamamanhid related to nursing rapport. better nursing intervention,
sa kamay at paa ko.” hypertension as intervention the connection with the client has no
As verbalized by the evidenced by Acethylcoline released by patient’s blood the client. elevation in her
patient. dizziness and prosta preganglionic pressure will blood pressure
numbness. neurons decreased to  To determine
Objective: acceptable limits. - Monitor vital normal and GOAL MET
 Restless signs abnormal
 Conscious Preganglionic fiber releases Long Term Goal: values. Long Term Goal:
and
coherent After 3 days of  Peripheral After 3 days of
 Able to Norepinephrine(constriction nursing - Observe skin vasoconstriction nursing intervention,
perform of blood vessel thereby interventions, color, may result in the client maintains
ADL’s increasing blood pressure the client will temperature, pale, cool, a stable blood
 Vital Signs as maintain normal capillary refill, clammy skin, pressure.
follows: and stable blood and diaphoresis. with prolonged
BP: 160/110 Adrenal medulla secrets pressure. capillary refill GOAL MET
mmHg epinephrine time.
RR: 22
breaths per  Hypertension is
min increased blood pressure - Emphasize the life time illness,
PR: 80 bpm causing it to increase blood concept of controlling it is
Temp: 36 supply in the brain causing controlling the best way to
O2 occipital headache hypertension stop it from
Saturation: rather than reoccurring.
98% curing it.
 To make the
- Promote bed patient feel
rest. relaxed and
reduced stress.
  Salty and fatty
- Encouraged food are one of
patient to the common
maintain low cause of
salt low fat diet hypertension.

Dependent:
Dependent:
 Inhibits influx of
- Administer Calcium ion
prescribed drugs across cell
(anti- membrane to
hypertensive) as produce
maintenance. relaxation of
coronary
smooth muscle.