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    Notes 240225 211143

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    jana white
    - The patient presented with dizziness and hypertension. Initial vital signs included a blood pressure of 130/80 mmHg, pulse of 86 bpm, respiratory rate of 36 bpm, and temperature of 36.6°C. The diagnosis was hypertension related to elevated blood pressure manifesting as an occipital headache. Short term and long term nursing goals were to decrease the patient's blood pressure through monitoring, observation, and assessment of underlying conditions.

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    Notes 240225 211143

    Uploaded by

    jana white
    16 views7 pages
    - The patient presented with dizziness and hypertension. Initial vital signs included a blood pressure of 130/80 mmHg, pulse of 86 bpm, respiratory rate of 36 bpm, and temperature of 36.6°C. The diagnosis was hypertension related to elevated blood pressure manifesting as an occipital headache. Short term and long term nursing goals were to decrease the patient's blood pressure through monitoring, observation, and assessment of underlying conditions.

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    - The patient presented with dizziness and hypertension. Initial vital signs included a blood pressure of 130/80 mmHg, pulse of 86 bpm, respiratory rate of 36 bpm, and temperature of 36.6°C. The diagnosis was hypertension related to elevated blood pressure manifesting as an occipital headache. Short term and long term nursing goals were to decrease the patient's blood pressure through monitoring, observation, and assessment of underlying conditions.

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    © All Rights Reserved
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    Download as docx, pdf, or txt
    16 views7 pages

    Notes 240225 211143

    Uploaded by

    jana white
    - The patient presented with dizziness and hypertension. Initial vital signs included a blood pressure of 130/80 mmHg, pulse of 86 bpm, respiratory rate of 36 bpm, and temperature of 36.6°C. The diagnosis was hypertension related to elevated blood pressure manifesting as an occipital headache. Short term and long term nursing goals were to decrease the patient's blood pressure through monitoring, observation, and assessment of underlying conditions.

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    ASSESSMENT

    - Able to perform ADL's with assistance


    - Dizziness noted
    - With initial vital signs of

    BP:130/80mmHg

    PR: 86 bpm

    RR: 36 bpm

    Temp: 36.6 c

    DIAGNOSIS
    hypertension related to elevated blood pressure
    as manifested by occipital headache

    Planning

    LTO: after 3 days of nursing interventions the


    client will maintain normal and stable blood
    pressure

    STO: end After 8 hours of nursing intervention


    the clients blood pressure will decreased to
    acceptable limits
    INTERVENTION
    - Assess underlying conditions
    - monitor blood pressure
    - Observe skin colour temperature capillary
    refills and diaphoresis

    RATIONALE
    - To determine what triggers the elevated BP
    - Change in B.P may indicate change in patient
    status required from medical attention.
    - peripheral vasoconstriction may result in pale,
    cool, clammy skin with prolonged capillary refill

    Evaluation
    STO:

    After 8 hours of nursing intervention the client


    has no elevation in his blood pressure
    Goal was met

    LTO: after 3 days of nursing intervention the


    patient maintains a stable blood pressure
    Goal was met
    ASSESSMENT
    S:
    O:
    - Facial grimaces
    - uncomfortable
    - Restlessness
    - With initial vital signs of
    BP:110/ 60mmHg
    PR: 96 bpm
    RR: 18
    Temp: 36.6 c

    DX: Acute labor pain r/t cervical dilatation

    PLANNING:
    SHORT TERM GOAL: After 8hrs of nursing
    interventions the patient will be able to engage
    in non pharmacologic measure to reduce
    discomfort/pain

    LONG TERM GOAL: After 24 nursing


    interventions the patient will be able to report
    pain management level

    NURSING INTERVENTION
    - Asses patient vital sign especially her blood
    pressure.

    - Provide/encourage use of comfort


    measures, like repositioning.

    - Teach patient to practice and emphasize


    constant and proper hand hygiene.

    - Relaxation is mostly taught in preparing for


    childbirth classes

    - Provide comfort.

    RATIONALE

    - To know any deviations from Normal range

    - Position changes enhance circulation


    reduce muscle tension.

    - By teaching patients how to perform effective


    hand hygiene techniques consistently, nurses
    help reduce infection risk and promote better
    overall health outcomes
    - By learning relaxation techniques, mothers can
    improve their coping skills and have a more
    positive childbirth experience.

    - it promotes a sense of well-being,


    reduces anxiety, and enhances the overall
    patient experience.
    EVALUATION
    SHORT TERM GOAL:
    After 8hrs of nursing interventions the patient
    was able to engage in non pharmacologic
    pressure to reduce discomfort/pain

    GOAL MET

    LONG TERM GOAL:


    After 24 of nursing interventions patient was be
    able to report pain at management level. GOAL
    MET

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