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ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
di na komasyadongmakatulong
dito sa bahaykasi mabilisakongmapagod
Objectives:
- W eak inappearance
- BP 150/90
Activityintolerancerelated tobodyweaknesssecondary tounderlyingdiseaseprocess
Diseaseprocess
Body needsincreasedeffort forsystemic
circulation
Increasedenergy used
in response tothe increased
workloadneeded
Lack ofenergy for
otherphysical
activities
Short Term:
After 2-3hours ofnursing
interventionthe patientwill identifynegativefactorsaffectingactivityintoleranceand how toreduce theireffects when
possible
Long Term:
The patient
will useidentifiedtechniques toenhance
Independent:
y Ascertainability tostand andmove aboutand degree ofassistancenecessary
y Identify and
prioritizeactivitiesneeded
y Reduceintensity level
or encourageto discontinueactivities thatcauseundesiredphysiologicalchanges
y Todeterminecurrentstatus andneedsassociatedwith desiredactivities
y To conserve
energy andavoid fatigue
y To preventoverexertion
After 3 hoursof nursinginterventionsthe patientidentifiednegativefactorsaffectingactivityintolerance
and how toreduce theireffects.
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ActivityIntolerance
activitytolerance
y Increaseactivity/exercisegradually
y Teachmethods toconserve
energy
y Balance restperiods withactivities
y Provide brief
informationabout thepatientscurrentcondition andhow to avoid
exacerbatingor worseningthe condition
y To preventy y overexertion
y To assistclient to dealwithcontributingfactors
y To preventfatigue
y To provideknowledgeto patientandencourageto avoid
sedentarylifestylethat willworsen hiscondition
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ASSESSMENT NURSINGDIAGNOSIS
INFERENCE PLANNING NURSINGINTERVENTION
RATIONALE EVALUATION
Subjective:
Para saan ba yung gamot ko?!
Objective:
-misunderstandingof the cause andtreatment of thedisease
-confused
-denial
Knowledgedeficit r/t
chronic diseasemanagement
Inheriteddisease
Age
Prolonged H PN
Unhealthylifestyle
lack ofinformationabout thedisease
Knowledgedeficit r/t
chronic diseasemanagement
After 30 minsof nursing care,the patient willverbalizeunderstandingof the disease
and themanagementthat can bedone.
Monitor clientsvital signs,especially BP
Define andstate the unitsof desired BP
Assist thepatient inidentifyingmodifiable riskfactors like diet
R einforce theimportance oftreatmentregimen andkeeping follow up
appointments
Encouragepatient todecrease oreliminate
caffeine like tea,coffee, cola and
For baselineparameter
Provides basisforunderstandingelevations of BP
This may havebeen shown tocontribute tohypertension
To avoidfailure ofcompliance tohisantihypertensivetherapy
Caffeine is acardiacstimulant andmay adverselyaffect cardiac
function
After 30 minsof nursing care,the patientverbalizedunderstandingof the disease
and themanagement tobe done.
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chocolates
Stressimportance ofaccomplishingdaily rest periods
Provideinformationregardingcommunityresources andsupport programsin makinglifestyle changes
Instruct thepatient or thesignificantothers on how totake bloodpressure
Tell the patientand family tokeep a record ofdrugs used in thepast
Suggest
To promoteadequate rest
Communityresources likehealth center
programs andcheck ups arehelpful inmonitoring BP
To monitorclients BP
To determineand evaluate themedicationbeing used
To have a
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ASSESSMENT NURSINGDIAGNOSIS
INFERENCE PLANNING NURSINGINTERVENTIONS
RATIONALE EVALUATION
Subjective:Hindi komapigilan angpaninigarilyoko.
Objective:
(+) Smoker (+) alcoholdrinker
B .P.: 150/90
IneffectiveHealth
Maintenancerelated to
Inability tomodify
lifestyle
Patient wassmoking sincehe was 17yrs.
Old
Patient ishypertensive
Patient wasntable to stopsmoking and
drinkingalcoholic
beverages.
Inability tomodify
lifestyle
After 2 hoursof nursinginterventionsthe patientwill learn andverbalizeunderstandingof factors
contributingto currentsituation.
Identify andteach the client ofthe factors thatcontributes tohypertension.
Evaluate clientfor substance use.
N ote settingwhere the clientlives.
Assess clientsdesire to learnabout his health.
Help the client tochoose a healthylifestyle.
This can helpthe client tolearn moreabout whatcauseshypertension.
Affectsclients
desire/abilityto help self. To note
individualadaptationneeds.
To know ifthe client iseager to helphimself.
Healthylifestylemeasures,
such asexercisingregularly,maintaining ahealthyweight, notsmoking, andlimiting alcoholintake, help
After 2 hoursof nursinginterventionsthe patientlearned andverbalizesunderstandingof factors
contributingto currentsituation.
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Discuss with
client realisticgoals for changesin healthmaintenance.
reduce therisk of beinghypertensiveand otherdiseases.
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ASSESSMENT NURSINGDIAGNOSIS
INFERENCE PLANNING NURSINGINTERVENTIONS
RATIONALE EVALUATION
Subjective:Madalas akongmahilo,asverbalized bythe patient.
Objectives:
(+) dizziness
(+) headache
B .P.: 150/90
DecreasedCardiacOutput
related toincreasedvascular
resistanceSecondary to
Hypertension
Hypertension
Decreasecircumference of
the arteriallumen
Increasesystemicvascular
resistance
R educed abilityof the heart to
pump effectively
Inadequate blood
pumped by theheart to meetthe metabolic
demands of thebody
DecreasedCardiac Output
Short-term:
After 6 hrsof nursinginterventions,the client will haveno elevation inblood pressure
above normallimits and willmaintainblood pressurewithinacceptable limits
Long-term:
After 5 daysof nursinginterventions,the client will
maintainadequate cardiacoutput.
Independent:
y Evaluatequality andequality ofpulses, asindicated.
y Auscultateheart soundsfor presenceof murmurs.
y Monitorheart rateand rhythm.
y N oteresponse toactivity andpromote restperiodappropriately
-Decreasedcardiac outputresults indiminishedweak/threadpulses which
suggestdysrhytmias.-To indicatedisturbancesof normalblood flowwithin theheart.-Heart rateand rhythmrespond tomedication,activity and
developingcomplications.-Overexertionincreasesoxygenconsumption/demand and cancompromisemyocardial
Short-term:
After 6 hrsof nursinginterventions,the client will haveno elevation inblood pressure
above normallimits and willmaintainblood pressurewithinacceptable limits
Long-term:
After 5 daysof nursinginterventions,the client
maintainedadequate cardiacoutput asevidenced byabsence of signsand symptoms.
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Dependent:
y Administersupplementaloxygen asindicated.
Collaborative:y Review serial
ECGs
y Monitorlaboratorydata (cardiacenzymes,ABgs,electrolytes)
function.
To increaseamount ofoxygenavailable formyocardialuptake,reducingischemia.
To provideinformationregarding.progression/resolutionofinfarction,status ofventricularfunction andeffects ofdrug
therapies.To identifycausative/contributingfactors
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y Refer to
nutritionistto providesmall/easilydigestedmeals. LimitcaffeineIntake(coffee,
chocolate,cola, asindicated)
Large mealsmay increasemyocardialworkload.Caffeine isdirectcardiacstimulantthat can
increaseheart rate.
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ASSESSMENT NURSINGDIAGNOSIS
INFERENCE PLANNING NURSINGINTERVENTIONS
RATIONALE EVALUATION
Subjective:
N ag-aalala akopag iniisip koang sakit ko.As verbalizedby the patient.
Objective:
y R estlessy Irritabley BP : 150/90
Mild anxietyrelated to
presentcondition
Diseaseprocess
Increasestress
perception
Unfamiliarcondition
about patients
health
Perceivedthreat to
health
R esulting tomild anxiety
After 1 hour ofnursing healtheducation/teachingto the patient andfamily members/significant others,
the client willdiminish and willbe relieve fromanxiety
-identify patientsperception of the
threatrepresented by
the situation
-Determine
current prescribedmedications and
recent drughistory of
prescribed or OTCmedications
-monitor physicalresponses: VS,
palpitations, rapidpulse, repetitive
movements, pacing.
-be aware ofdefense
-to assesslevel ofanxiety
-These
medicationscan heightenfeelings/sense
of anxiety
-to identifyphysical
responsesassociated
with bothmedical andemotionalconditions.
-that
-after nursinghealth
teaching thepatient
understandsthe purpose of
the educationand willing todo the
interventions.
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mechanism beingused. may be
denial, regression
and so forth andencourage patientto acknowledgeand to express
feelings.
-provide accurateinformation aboutthe situation. Helppatient to identify
what is realitybased.
-be available topatient for
listening andtalking.
-reviewhappenings,
thoughts andfeelings precedingthe anxiety attack.
interfere withability to dealwith problem.
-to build
rapport andtrust.
-to helppatient relieve
anxiety
-to helppatient relieve
anxiety
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ASSESSMENT NURSINGDIAGNOSIS
INFERENCE PLANNING NURSINGINTERVENTIONS
RATIONALE EVALUATION
Subjective: -
Objective:
-weight: 51kg
-BMI: 17.6(underweight)
Normal: 20-25
-(+) fatigue
-(+) dizziness
Imbalance
nutrition:less thanbody
requirementsr/t lack ofinformation
Lack of
information
Unhealthylifestyle
Lack ofknowledge of
eatinghealthyfoods
Imbalancenutrition:less than
bodyrequirements
After 1 hour
of nursingintervention,the clientandsignificantothers willable todemonstratebehaviors,lifestylechanges toregainand/or
maintainappropriateweight
y Ascertain
understandingof individualnutritionalneeds
y N oteavailability/use offinancialresources andsupportsystems
y Asses weight;measure/calculate body fatand musclemass viatriceps skin
fold andmidarm musclecircumferenceor otheranthropo-metricmeasurements
To determine
information needs ofclient/SO
To establish baselineparameters
After 1 hour
of nursingintervention,the client andsignificantothers wasable todemonstratebehaviors,lifestylechanges toregain and/ormaintainappropriate
weight
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y N ote age,body
build,strength,activity/restlevel, etc.
y Use flavoringagents
y R efer to homehealthresources
Helps determinenutritional needs
To enhance foodsatisfaction andstimulate appetite
Forinitiation/supervisionof home nutritiontherapy when used
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Health Problem Family Nursing
Problem
Goal of Care Objectives of
Care
Intervention PlanNursing
Interventions
Method of
Nurse-FamilyContact
Resources
Required
N oncomplianceto medicationregimen as a
health deficit
Inability toprovide
sufficientsupply for the
medication.
Insufficientmoney to
sustain theneed for drugmaintenance.
After nursingintervention thepatient and thefamily will takethe necessary
measures tomanage andcontrol the
propercompliance to
the medication.
After nursingintervention thefamily will:
have adequateknowledge or
ideas on howthey will beable to findsource ofincome.
be able todetermine the
risk ofnoncomplianceto medication.
be able tocomply for themedicationregimen.
Discuss thenature, signs,symptoms andcomplicationsthat might
arise due tononcomplianceto themedication.
Provideinformation andhelp the family
to know whereand how to findsource ofincome.
Encourage thefamily to joincommunity
activities orprograms thatwill help provideextra income.Provide
sufficientfinancial
support for themedication.
Home Visit Humanresources:
Time and efforton the part of
the studentnurse and
family
Financialresources:
Money for thestudent nursetransportation
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Provideknowledgeabout thebenefits of
complying themedication andits risks if not.
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Health Problem Family Nursing
Problem
Goal of Care Objectives of
Care
Intervention PlanNursing
Interventions
Method of
Nurse-FamilyContact
Resources
Required
N oncomplianceto medicationregimen as a
health deficit
Inability toprovide
sufficientsupply for the
medication.
Insufficientmoney to
sustain theneed for drugmaintenance.
After nursingintervention thepatient and thefamily will takethe necessary
measures tomanage andcontrol the
propercompliance to
the medication.
After nursingintervention thefamily will:
have adequateknowledge or
ideas on howthey will beable to findsource ofincome.
be able todetermine the
risk ofnoncomplianceto medication.
be able tocomply for themedicationregimen.
Discuss thenature, signs,symptoms andcomplicationsthat might
arise due tononcomplianceto themedication.
Provideinformation andhelp the family
to know whereand how to findsource ofincome.
Encourage thefamily to joincommunity
activities orprograms thatwill help provideextra income.Provide
sufficientfinancial
support for themedication.
Home Visit Humanresources:
Time and efforton the part of
the studentnurse and
family
Financialresources:
Money for thestudent nursetransportation
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Provideknowledgeabout thebenefits of
complying themedication andits risks if not.
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Health Problem Family Nursing
ProblemGoal of Care Objectives of
Care
Intervention PlanNursing
InterventionsMethod of
Nurse-FamilyContact
ResourcesRequired
Hypertension Inability tomake decisionswith respect to
takingappropriate
health actionsdue to lack of
adequateknowledge inthe nature of
the healthproblem.
After nursingintervention thefamily will takethe necessarymeasures to
properlymanage, control
and lessen therisk factors ofhypertension.
After nursingintervention thefamily will:
have adequateknowledgeabout propernutrition that
will help reducehypertension.
be able todetermine therisk factorsthat contributeto hypertension
practiceproper lifestylewith regards tonutrition andphysical fitness.
Discuss thenature, signs,symptoms andcomplicationsthat mightarise due tohypertension.
Discuss withthe family therisk factors ofhypertensionsuch as familyhistory, age,salt and alcohol
intake andobesity.
Promote ahealthylifestyle suchas encouragingproper food
intake likereduced saltand fattyfoods.
Imply theimportance ofhaving an
exercise. Discuss ways
Home Visit Time andeffort on thepart of thestudent nurseand family
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in Smokingcessation.
Deliberatethat tobacco or
nicotinepromotesatherosclerosisthat maycontribute tohypertension.
Encourage
check-ups andprovidereferral with amedicalpractitioner tolessenhypertension
and modifyrisk-factors.
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Health Problem Family Nursing Problem Goal of Care Objectives of
Care
Intervention PlanNursing
InterventionsMethod of
Nurse-FamilyContact
ResourcesRequired
Hypertension asa health threatto the rest of
the family
1. Inability tomanagedhypertension dueto lack ofknowledge aboutthe condition.
2. Inability to make
decisions withrespect to takingappropriate healthaction on thehealth threat dueto failure tocomprehend to the
nature of theproblem.
3. Inability toprovide a homeenviron-mentconducive tohealth
maintenance dueto:a. Ignorance of
preventivemeasures
b. Inadequatefamily
resourcesspecifically
After nursingintervention, the
possibility ofuncontrolled
hypertension willbe minimized or
prevented.
After nursingintervention thefamily will:
Correct wrongnotions aboutthe cause ofhypertension.
R ecognizebeginning casesof hypertensionand applypreventive/therapeuticmeasures.
Discuss thenature, signs,symptoms andcomplications ofhypertension ifpropermanagement is
not done.Explore with
the family waysof implementingmeasures tomaintain propermanagement
and preventionofhypertension.
Home Visit Humanresources:
Time and efforton the part ofthe studentnurse and
family
Financialresources:
Money for thestudent nurse
transportation
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financialrsources