Nursing Care Plan

[deanikins211]

I am starting to make a nursing care plan. Hope you guys can help me.

problem: severe hypertension

nursing diagnosis:cardiac output,risk for increase vascular resistance, vasoconstriction.

I already have the intervention as well as the rationale but my problem is i don't know how to make an objective and subjective asessment. And also can you help me make the goals??And can you also help me derive long term and short term objectives??please..

Can you help me or advise me on how to do it??

please..really need your help.

[chevyv, BSN, RN]

Your subjective data is what the patient or family tells you. This is in quotes. Ideally, the patient will give you input, but family is ok too. Example: "I get dizzy when I first stand up.". It's what the patient tells you, nothing more and nothing less.

Your objective data would be any meds, dosages, how often taken, as well as blood pressures taken while you were on site. Example if your there two days, I would take a look into the chart and post day, pm, and noc bp. Also, note the apical pulse, and S1, S2 (any other heard), the rate (reg or irreg), and rhythm (reg or irreg). Gallops or murmurs (no or yes), pedal and tibial pulses (are they palpable bilaterally?), Nailbeds (color, capillary refill time less than 3 sec or longer in all extremities), any edema? any jugular venous distension?, mucous membranes (are they moist and intact?), is the pt on telementary (if yes, what does it show?)

List any pertinent labs (are they low/high/ or wnl?) and any other tests

List pertinent hx.

This seems like alot to cover, but it gives you a good pic of cardiac. I hope this helps a bit.

[chevyv, BSN, RN]

i found my sheets from 2nd semester. they may help you more than my previous post.

pa nurse practice act and ana defines nursing as the diagnosis and treatment of human responses to actual and potential health problems

nursing process

5 steps

• assess
  
• diagnose
  
• plan
  
• implement
  
• evaluate

4 steps

• assess
  • diagnose

  [*]plan

  [*]implement

  [*]evaluate

step 1 assessment

• initial step
  
  
• ongoing/ component of every step
  
  
• collect data

validate

communicate

types of data

• subjective
  
  
• objective

subjective

"symptom"

information apparent only to person experiencing it

cannot be validated by someone else for example

includes pts perception of his situation-human response

objective

"sign"

can be observed - seen, heard, felt smelled

can compare to some standard

e.g. increased pulse rate

but. due to temp

environment

anxiety

etc.

sources of data

• primary
  • always the patient

  [*]secondary

  • family, s/o other health care personnel, medical records, lab reports, literature

for mr. r:

subjective data

primary

secondary

objective data

primary

secondary

i have much more detailed sheets, but this site won't allow me to paste the entire sheet. something about too many images. if you need more, let me know and i'll post in seperate replies

[Daytonite, BSN, RN]

you can't have any significant nursing diagnoses and interventions that relate to the patient's problems without having any assessment information from which to analyze those problems.

all nursing diagnoses are based upon evidence of abnormal data that can only be found after doing a thorough assessment of the patient.

nursing interventions are focused on the abnormal data, or symptoms, you found in the patient during the assessment.

goals reflect how you expect the patient will respond as a result of the nursing interventions you will order. this post will help show you how to write goal statements:

• https://allnurses.com/forums/2509305-post157.html

for a patient with hypertension you will want to assess the cardiovascular system. you will find a guideline for a cardiovascular assessment on this thread:

• https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html - health assessment resources, techniques, and forms (in nursing student assistance forum)

here is the pathophysiology of hypertension:

• https://allnurses.com/forums/f50/help-pathophys-hypertension-295077.html

(from page 25, nursing care planning made incredibly easy published 2008 by lippincott williams & wilkins):

assessment findings fall into two broad categories:

1. "objective data -
   objective data come from the physical examination through inspection, percussion, palpation, and auscultation. use physical findings to verify the subjective findings you've gathered from the patient's health history.
   "
   
   
2. "subjective data -
   subjective assessment data represents the perception or reality experienced by the person reporting the information. it may come directly from the patient or indirectly from family members, caregivers, or other health care providers."