DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.
COLLEGE OF NURSING
A.Y. 2023-2024
1st Semester
NURSING CARE PLAN
NURSING SCIENTIFIC
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS RATIONALE
SUBJECTIVE: Risk for SHORT TERM INDEPENDENT INDEPENDENT GOAL WAS MET
“malipong tak Decreased Elevated blood pressure
ulo ngan Cardiac (hypertension) and After 8 hours of nursing 1. Monitor vital 1. Regular monitoring of After 8 hours of
nanluluya ak. Output increased heart rate can intervention, the patient signs closely blood pressure, heart rate, nursing intervention,
Ngan danay related to indicate increased cardiac will be able to: and rhythm provides the patient was able
nagsisinakit hit hypertension workload, which may lead valuable information to:
likod tak ulo urgency and to decreased cardiac 1. Maintain about cardiac function and
ngada may possible output. This can result in adequate helps identify changes 1. Maintain
Hirani liog cardiovascul inadequate tissue cardiac output. that may indicate adequate
dapit” as ar infarction perfusion and 2. Minimize decreased cardiac output cardiac output.
verbalized by oxygenation, increasing myocardial or worsening 2. Minimize
the patient. the risk of complications oxygen cardiovascular status. myocardial
such as myocardial demand. oxygen
OBJECTIVE: infarction (heart attack) or 3. Prevent 2. Assist with 2. Proper positioning, such demand.
• BP: stroke. complications positioning such as elevating the head of 3. Prevent
160/100 related to as elevation of the bed, can reduce complications
mmHG decreased the head venous return to the heart related to
• HR:98 cardiac output. and decrease cardiac decreased
bpm workload, thereby cardiac output.
• Patient optimizing cardiac output.
appears
fatigued
• Nape 3. Lifestyle changes,
pain with 3. Educate the including dietary
PRS of 7 patient on modifications, regular
Source: Nair, R. (2020). lifestyle exercise, smoking
Hypertension. StatPearls
Publishing. modification cessation, and stress
https://www.ncbi.nlm.nih.gov/books/ management, can help
NBK470470/
DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.
COLLEGE OF NURSING
A.Y. 2023-2024
1st Semester
control hypertension and
reduce the risk of
cardiovascular events.
4. Anxiety and stress can
exacerbate hypertension
and negatively affect
4. Provide cardiac function.
emotional support Providing emotional
and reassurance support and reassurance
can help alleviate anxiety
and promote relaxation.
COLLABORATIVE COLLABORATIVE
1. Administer
medication as 1. Medications such as
prescribed antihypertensives or
antiplatelet agents may
be prescribed to manage
hypertension and prevent
complications such as
myocardial infarction.
Source: Williams, B., Mancia, G.,
Spiering, W., et al. (2018). 2018
ESC/ESH Guidelines for the
management of arterial hypertension.
European Heart Journal, 39(33), 3021–
3104.
DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.
COLLEGE OF NURSING
A.Y. 2023-2024
1st Semester
NURSING CARE PLAN
NURSING SCIENTIFIC
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS RATIONALE
SUBJECTIVE: SHORT TERM INDEPENDENT INDEPENDENT GOAL WAS MET
“Nanluluya ak Activity Poor muscle tone and
perme ngan Intolerance strength can result from After 8 hours of 1. Assess 1. A comprehensive After 8 hours of
madali laak related to various factors, including nursing intervention, mobility assessment helps identify the nursing
kapoyun” as poor cardiovascular disease, the patient will be able status and extent of the patient's activity intervention, the
verbalized by muscle hypertension, and urinary to: functional intolerance and guides patient was able to:
the patient. tone and tract infection, all of which limitations individualized interventions.
strength are present in this patient. 1. Improve 1. Improve
OBJECTIVE: Cardiovascular disease and muscle tone 2. Encourage 2. Gradual increases in physical muscle tone
• Patient hypertension can lead to and strength. progressive activity help build endurance and
was reduced cardiac output and 2. Enhance the ambulation and muscle strength while strength.
seen peripheral perfusion, patient's ability reducing the risk of fatigue 2. Enhance
strugglin contributing to muscle to perform and injury. the patient's
g with weakness and fatigue. activities of ability to
mobility Additionally, the daily living. 3. Implement 3. Teaching energy-saving perform
• Decreas inflammatory response 3. Prevent energy techniques reduces the activities of
ed associated with urinary tract complications conservatio energy expenditure required daily living.
muscle infections can further associated n for activities, enabling the 3. Prevent
tone and exacerbate muscle with prolonged techniques patient to conserve strength complicatio
strength weakness. immobility. and endurance. ns
• Reluctan associated
t to with
engage prolonged
in 4. Provide 4. Mobility aids such as canes immobility.
physical assistive or walkers promote stability
activity devices as and support during
needed ambulation, reducing the risk
DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.
COLLEGE OF NURSING
A.Y. 2023-2024
1st Semester
of falls and facilitating activity
Source: Morris, D., & Hare, D. (2016). participation.
Cardiovascular disease and the role of
microbiota and metabolites.
10.1016/B978-0-12-801816-3.00014-9. 5. Monitor vital 5. Regular monitoring of vital
signs during signs helps assess the
activity patient's tolerance to activity
and detect signs of
cardiovascular compromise.
6. Educate the 6. Teaching the patient to
patient on balance activity and rest
pacing periods prevents
activities. overexertion and conserves
energy, improving overall
endurance.
COLLABORATIVE COLLABORATIVE
1. Collaborate 1. Physical therapists can
with design tailored exercise
physical programs to improve muscle
therapy strength and mobility,
promoting independence in
activities of daily living.
Source: American Heart Association. (2020).
Exercise and cardiovascular health.
DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.
COLLEGE OF NURSING
A.Y. 2023-2024
1st Semester
