Data Subjective: The client verbalized: Medyo nahihilo ako Medyo masama pa rin ang pakiramdam ko .

120/80 ang normal kong BP pero minsan tumataas . Objective:  BP- 150/90  Urine output <30cc/hr  Bipedal Edema

Nursing Diagnosis

Background Knowledge Normal blood pressure ranges from : S:90-130 D:60-90 Decreased urine output is an effect of operation and anesthesia that complicate postpartum bladder changes. The bladder is less sensitive. Possible water retention resulting to increases blood volume.

Goals

Intervention

Rationale

Evaluation

Hypertension related to increased cardiac output and blood volume as evidenced by:  Verbalization of increased BP previously  Verbalization of feeling of dizziness  increased blood pressure above normal range  decreased urine output  bipedal edema

Long Term Goals: After 4 hours of continuous nursing intervention, the client will display hemodynamic stability.

Established rapport.

For effective communication and better Nurse-client interaction. To prevent discomfort.

Assisted the patient in comfortable position. Checked the vital signs.

Short term Goals: After 2 hrs comprehensive nursing intervention, the client will be able to:  verbalize nature of hypertension accurately.  Enumerate at least 3 causes of hypertension Edema is the  Enumerate and accumulation of explain at least 2 fluid in the tissues management of under the skin as hypertension. a result of leakage  Participate in of water from the patient blood vessels to monitoring and tissues. activities that will decrease Increased blood blood pressure. pressure does not  Manifest normal appear to cause BP dizziness but it is  Elevate the feet a side effect of about 45-60 some high blood degrees.

For q1 monitoring and to determine abnormal v/s To determine fluid imbalances.

Measured level of fluids, intake and urine output. Explained the nature of hypertension by stating its definition.

To provide knowledge regarding the present problem and to prevent complications in the future. To provide knowledge about the problem.

Explained the causes of hypertension including:  Kidney abnormalities  History of hypertension  Illegal use of drugs

Goals met.  The client verbalized the nature of hypertension by stating its definition accurately.  Enumerated the causes of hypertension including kidney abnormalities, history in the family and illegal drug use.  Explained 2 management of hypertension including increased fluid intake and intake of proper medicine.  Increased oral fluid intake.  Verbalized encouragement in shifting of position by stating that it is important to prevent bedsores.

pressure medications, especially alpha blockers and alpha-beta blockers.

 Increase oral fluid intake about 30-60 cc per hour.  Verbalize encouragement in proper positioning.  Verbalize encouragement to consult dietician.

Explained management of hypertension such as:  Pharmacologic management -alpha blockers -alpha beta blockers  Non-pharma cologic management: -low Na+ low fat diet

To provide knowledge. For the client to fully maintain optimal health.

Goal Unmet:  The client did not verbalize encouragement in consulting a dietitician.  BP not normal (140/80)  Urine output <30cc/hr

To provide knowledge about alternative management. To decrease Blood Volume, hence decreasing BP To increase urine output

-increase fluid intake (30-60 cc/hr) -healthy lifestyle -exercise  Instructed the client to elevate feet about 4560 degrees

To promote wellness

To reduce edema of the feet.

 Encourage the patient to shift position every 2 hours.  Encourage to consult dietician

To prevent pressure ulcer.

To prevent further increase of BP in the

about the proper diet management.

future.