ASSESSMENT P#1: Hypertension S: Chest pain rated as 5-6/10 O:> v/s: BPPRRRTO guards the chest when in pain

n and guards the head when he feels dizzy capillary refill at 1 sec. wit regular rhythm of pulse rate slightly pale skin, conjunctiva and nail beds skin is warm to touch, (-) edema, (+) good skin turgor patient prefers sitting position A: Decreed cardiac output related to increase vascular resistance.

EXPLANATION OF THE PROBLEM

OBJECTIVE STO: After 8 hours of nursing intervention, the patient will be able to: a. decrease chest pain from 5-6 to 3-4/10. b. decrease his BP from 150/100 to 130-140/8090. LTO: After 2-3 days of nursing intervention, the patient will be able to maintain BP within is acceptable range such as 130/90.

INTEVENTION Dx: Monitor vital signs especially BP and PR.

RATIONALE

EVALUATION

Assess patients response to increase activity.

Assess contributing factors in increasing / elevation of BP. Note skin color and presence and quality of pulse.

It serves as baseline data that will help in the evaluation and planning for therapeutic intervention. Physical activity increases the demand placed on the heart. Close monitoring of patients response serves as a guide for optimal progression of activity. It serves as a guide or baseline data and so appropriate plan of care plan are initiated. Peripheral circulation is reduced when cardiac output falls,

giving the skin pale color and diminishing the strength of peripheral pulses. Tx: Place patient semi-fowler position. Maintain bed / chair rest in position of comfort during cute episodes. To reduce preload and ventricular filling. Decreases oxygen consumption / demand, reducing myocardial workload and risk of decompensation. Conserves energy, reduces workload.

Provide for adequate rest periods. Assist wit perform self-care activities, as indicted. Ensure safety by It is when the putting side rails. patient is dizzy. He tends to fall because of it and so to prevent it, we should ensure safety. Administer

medications prescribed by physician like ******. Ed: Explain symptoms and interventions for the illness.

Explain drug regimen, purpose and side effects.

Explain diet program for him.

To provide the ptient information about his illness and to be able to gain his cooperation for the planned interventions. For the ptient to understand and be aware if why those drugs were given to him. For side effects, it is very important for him to know it because it will help him on how to prevent further problems like the side effects of the specific drug. To provide him information about his diet and so to gain his cooperation for the planned

 Stress importance of avoiding straining especially during defecation.

intervention. Valsalva maneuver causes vagal stimulation, reducing heart rate which may be followed by rebound tachycardia, both of which may impair cardiac output.