Introduction Background of the study HYPERTENSION Significance of the study: Scope and limitation of the study Goal and objectives: Overview of disease Anatomy and physiology of affected system
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Biographic data Name: Patient s Address: Poblacion, Angat, Bulacan Age: 56 Gender : Male Civil status: Married Educational Educational level: High school Undergraduate Religious affiliation: Roman Catholic Occupation: Occupation: Farmer
Nursing history Past Health history 1. Childhood illness chicken pox 2. Immunizations - fully fully immunized 3. Allergies - Peanuts 4. Accidents Vehicular accident in right arm 5. Hospitalizations Hospitalizations 6. Medications used or currently taken History of present illness What happened to patient prior to hospitalization? The patient ate fatty foods in the wedding of her daughter that causes increase his blood pressure.
Sign and symptoms observed prior to hospitalization The patient experienced dizziness, body malaise, discomfort, facial grimace. Medication given prior to hospitalization Not applicable
Family history Hereditary disease of family According According to the patient his father and his grandfather had hypertension IV. Activities of daily living
ADL
Before hospitalization
Actual hospitalization
Interpretation and analysis
Nutrition Elimination activity Hygiene Substance use Sleep and rest Sexual activity
V. Physical assessment Normal
Actual findings
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General Appearance Mood and affect Signs of distress Posture Body Movement Hygiene and grooming Types of clothing Q uantity uantity and quality of speech Relevance and organization of thoughts y y y y y y y
y
Vital signs Body temp Pulse rate Respiratory rate Blood pressure
36.5 C-37.5 C 60-100 BPM 16-20 BPM 120/80mmHg °
°
36.9 C 110 BPM 30 BPM 150/100 mmHg °
Interpretation and analysis
Generic / Trade name
Dosage / Frequency
Classificatio n
Indication
Contraindicat ion
Side effects
Nursing Responsibiliti es
VII. Drug study
VIII. Pathophysiology Pathophysiology IX. Prioritization Nursing problem Hypertension
Cues Tachypnea, Pallor, Tachycardia Dizziness, Discomfort, Body Malaise
Justification The patient experienced this cues due to increase blood pressure.
