ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION SCIENTIFIC EVALUATION
DIAGNOSIS RATIONALE
Subjective Decreased Structural After 8 hours Independent: Independent: Goal partially
Data: Cardiac changes in the of nursing met.
"Usahay kapoy Output heart and blood interventions 1. Monitor BP, heart 1. Monitoring BP After 8 hours of
ako pamati, nya vessels , the patient rate, and oxygen and oxygen intervention, the
related to
mura kog (cardiomegaly will saturation every 4 levels ensures patient showed no
malipong" as increased and demonstrate hours. early detection of improvement in
verbalized by cardiac atherosclerosis) improved 2. Assess for signs worsening BP
the patient. workload reduce the heart's cardiac of worsening heart cardiac function. (140/80mmHg),
secondary to efficiency in output as failure such as 2. Identifying signs reported reduced
cardiomegaly pumping blood. evidenced by edema, crackles, of heart failure fatigue, and
and This can lead to stable BP, jugular vein allows for timely demonstrated
decreased and distention. intervention. understanding of
atherosclerosi
Objective Data: oxygen supply to improved 3. Encourage a 3. A low-sodium heart disease
Vital signs: s as tissues, energy low-sodium, diet helps management.
T- 36.2 evidenced by increasing the levels. heart-healthy diet. manage blood Continued
P- 67 elevated BP risk of heart 4. Position the pressure and monitoring and
R- 20 and reports of failure, ischemia, patient in a fluid retention. follow-up are
-BP: fatigue. or other semi-Fowler’s 4. Proper required.
140/80 mmHg complications. position to positioning
O2 Sat- 96 Thoracic facilitate improves lung
-Chest X-ray spondylosis may breathing. expansion and
results: further limit 5. Encourage deep reduces the
Cardiomegaly mobility and breathing workload on the
Atherosclerotic affect respiratory exercises and safe heart.
Aorta effort. physical activity 5. Physical activity
Thoracic to improve promotes
Spondylosis circulation and circulation and
-Limited reduce prevents
mobility complications of musculoskeletal
-Uses walker thoracic complications.
spondylosis 6. Education
6. Educate the increases the
patient and family patient’s
on heart disease adherence to
management, treatment and
lifestyle reduces the risk
modifications, and of complications.
medication
adherence. Dependent:
1. Medications help
Dependent: control
hypertension and
1. Administer prevent fluid
antihypertensive overload.
medication as
prescribed by
physician.
● Bisoprolol
5mg /1 tab PO OD
6am
● Candesartan
16 mg 1 Tab PO
OD 7 am
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION SCIENTIFIC EVALUATION
DIAGNOSIS RATIONALE
Subjective Ineffective Hypertension After 8 hours Independent: Independent: Goal partially met.
Data: peripheral leads to of nursing
"Usahay kapoy tissue increased interventions, 1. Assess vital 1. Regular BP After 8 hours of
ako pamati, nya perfusion afterload, the patient will signs every 4 monitoring nursing interventions,
nya mura kog related to causing demonstrate hours especially evaluates the patient’s BP did not
malipong" as increased inadequate improved BP BP. response to decrease to 120/80
verbalized by vascular oxygenation (within normal 2. Assess signs of treatment. mmHg. However, the
the patient. resistance and perfusion range) and end-organ 2. Early detection patient verbalizes relief
secondary to to vital organs. verbalize damage such as prevents from dizziness.
Objective Data: hypertension If untreated, relief from chest pain, complications.
Vital signs: as evidenced this may result dizziness. confusion and 3. Certain
T- 36.2 by elevated in stroke, shortness of medications
P- 67 BP and myocardial breath. can cause
R- 20 reports of infarction, or 3. Assess for side dizziness due
-BP: dizziness. organ damage. effects of to their effects
140/80 mmHg antihypertensive on blood
O2 Sat- 96 medications. pressure and
-Chest X-ray 4. Educate about fluid balance.
results: hypertension, 4. Patient
Cardiomegaly complications, education
Atherosclerotic and medication ensures
Aorta compliance. adherence to
Thoracic 5. Encourage treatment.
Spondylosis low-sodium 5. Lifestyle
-Limited diet, and avoid changes help
mobility processed foods. maintain BP.
-Uses walker 6. Promote 6. Fatigue and
adequate rest lack of sleep
and sleep. can worsen
7. Instruct patient dizziness by
to change affecting
positions slowly balance and
such as sitting cognitive
before standing function.
and standing 7. Prevents
before walking. orthostatic
8. Encourage hypotension, a
ambulation to common cause
promote blood of dizziness in
circulation with older adults.
the support of 8. Ambulation
family promotes
members. vasodilation,
reducing
Dependent: vascular
resistance and
2. Administer helping to
antihypertensive lower blood
medication as pressure.
prescribed by
physician. Dependent:
● Bisoprolol 1. Medications
5mg /1 tab PO control BP,
OD 6am reducing
● Candesartan cardiac
16 mg 1 Tab PO workload.
OD 7 am
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION SCIENTIFIC EVALUATION
DIAGNOSIS RATIONALE
Subjective Data: Decreased Activity Insufficient After 8 hours, Independent: Independent: Goal Partially
“Lisod kaayo Tolerance related endurance to the patient will Met.
maglihok, dali ra to impaired complete required demonstrate 1. Assess the 1. Establishes
ko kapuyan. physical mobility or desired daily improved patient’s baseline After 8 hours of
Kinahanglan ko'g as evidenced by activities. The use mobility and activity level, mobility nursing
tabang kung limited range of of a walker perform muscle and interventions, the
maglakaw ug kung motion, use of a suggests muscle simple strength, and monitors patient
moihi." as walker, and need weakness or activities such signs of progress. demonstrated
verbalized by the for assistance with balance issues, as sitting, fatigue before 2. Prevents slight
patient. urination. while difficulty standing and and after overexertio improvement in
urinating with the walking short movement. n and activity tolerance
need for distances with 2. Encourage enhances but still required
Objective Data: assistance may be minimal gradual endurance. assistance for
Vital signs: due to decreased fatigue. activity such 3. Promotes mobility and
T- 36.2 strength, poor as sitting up independen toileting. Patient
P- 67 coordination, or and ce and was able to sit up
R- 20 underlying short-distance prevents and stand with
-BP: medical walking urinary support but
140/80 mmHg conditions. while discomfort. experienced
O2 Sat- 96 ensuring 4. Ensures fatigue after
-Chest X-ray safety. energy short-distance
results: 3. Provide conservatio walking.
Cardiomegaly assistance n and Assistance with
Atherosclerotic with toileting prevents toileting was still
Aorta and fatigue. required, but the
Thoracic encourage a 5. Enhances patient showed
Spondylosis toileting safety and increased effort
-Limited mobility schedule to reduces fall in repositioning.
-Uses walker prevent risk.
accidents. 6. Maintains
4. Allow rest joint
periods mobility
between and
activities to prevents
prevent complicatio
exhaustion. ns.
5. Support
mobility
using the
walker and
ensure a safe
environment
ensuring
clear
pathways and
proper
lighting.
6. Encourage
range of
motion
(ROM)
exercises to
prevent
stiffness and
improve
flexibility.
ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION SCIENTIFIC EVALUATION
DIAGNOSIS RATIONALE
Subjective Deficient Lack of After 8 hours, the Independent: Independent: Goal Met
Data: knowledge knowledge patient and After 8 hours, the
"Wala ko kasabot regarding about family will 1. Assess the 1. Identifies patient and family
ngano taas permi condition, hypertension, verbalize patient’s current knowledge gaps accurately
akong BP bisan therapeutic heart disease, understanding of knowledge about and helps tailor verbalized their
nagsunod ko sa regimen and and lifestyle disease hypertension, its education to the understanding of
tambal. Last potential modifications management, causes, and patient’s needs. hypertension
december na complications may lead to poor medication management. 2. Ensures the management,
hospital pod ko related to lack of adherence to compliance, and 2. Explain patient including:
tungod ani. information as treatment and lifestyle changes. hypertension in comprehends the
Unsay angay evidenced by increased simple, condition, which -The importance
buhaton aron statement of complications. understandable promotes of medication
malikayan ang concerns and lack terms using adherence to compliance (e.g.,
komplikasyon of BP control. vernacular treatment. correct dosage
ani nga sakit?" as language.. 3. Helps the patient and timing).
verbalized by the 3. Educate the understand the -Necessary
patient. patient on the consequences of lifestyle
importance of uncontrolled modifications
blood pressure hypertension, (e.g., low-sodium
Objective Data: control and motivating diet, regular
Vital signs: potential adherence. exercise).
T- 36.2 complications 4. Empowers the -Recognition of
P- 67 such as stroke, patient to track potential
R- 20 heart disease their BP trends complications
-BP: and kidney and seek timely (e.g., stroke,
140/80 mmHg damage. medical kidney disease).
O2 Sat- 96 4. Teach the patient intervention if -Proper blood
-Chest X-ray how to properly necessary. pressure
results: monitor blood 5. Enhances monitoring at
Cardiomegaly pressure at medication home.
Atherosclerotic home. adherence and
Aorta 5. Provide prevents
Thoracic information on complications
Spondylosis prescribed from improper
-Limited medications, use.
mobility including their 6. Non-pharmacolo
-Uses walker purpose, proper gical approaches
administration, significantly
and potential contribute to BP
side effects. control and
6. Encourage overall
lifestyle cardiovascular
modifications, health.
such as a 7. Provides
low-sodium diet, additional
weight support and
management, reinforcement to
regular exercise, help the patient
and smoking maintain BP
cessation. control.
7. Involve family 8. Promotes active
members or learning and
caregivers in the helps clarify
education misconceptions.
process. 9. Ensures that the
8. Encourage the patient has
patient to ask correctly
questions and understood the
express teaching.
concerns.
9. Use teach-back
method to
confirm that a
patient Dependent:
understands the
information 1. Helps manage
given by having blood pressure
them explain it effectively while
back in their own the patient learns
words. about the
importance of
Dependent: adherence.
3. Administer
antihypertensive
medication as
prescribed by
physician.
● Bisoprolol
5mg /1 tab PO
OD 6am
● Candesartan
16 mg 1 Tab PO
OD 7 am
