Professional Documents
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Assessment
Subjective data:
• ´´I experience pain while passing urine, headaches, headaches, I do not see well, and even
after doing something small, I become very tired easily and for the first time I have
experienced nose bleeding. So I do not understand what is happening to me these days´´
verbalised Mr Neck.
Objective data:
• Decreased cardiac output
• Decreased stroke volume
• Increased peripheral vascular resistance
• Vitals taken as follows:
-Temperature: 37.2 °C
-Pulse rate: 83beats/minutes
-Respiration rate: 18breaths/minutes
-Blood pressure: 180/100mmHg
Nursing diagnosis:
Knowledge deficit related to the underlying heart disease, its consequences and treatment regimen
evidenced by verbalisation of patient.
Nursing diagnosis
Anxiety, related to potential for lifestyle modification, intensive care setting and diagnosis made
evidenced by patient verbalising feelings of fears.
Nursing diagnosis
Decreased Cardiac Output related to malignant hypertension as evidenced by decreased stroke
volume.
Goal Nursing intervention Rationale Evaluation
Short term goal 1. Monitor BP every 1.To monitor Short term goal
After 6 hours of 1-2 hours, or every baseline data. After 8 hours of
nursing 5 minutes during nursing
interventions, the active titration of interventions, blood
client will have no vasoactive drugs. pressure maintained
elevation in blood within set
pressure above parameters for the
2. Monitor ECG for 2. Caffeine is a
normal limits and client.
dysrrhythmias, cardiac stimulant
will maintain blood Goal was met.
conduction defects and may adversely
pressure within and for heart rate. affect cardiac Long term goal
acceptable limits.
function. After 6 days of
Long term goal nursing
After 5 days of 3. Suggest frequent 3. These drugs have interventions, the
nursing position changes. rapid action and client had an
interventions, the may decrease the adequate tissue
client will maintain blood pressure too perfusion to his
adequate cardiac rapidly, resulting in body systems.
output and cardiac complications. Goal was met.
index.
4. Encourage patient 4. May indicate
to decrease intake of cyanide toxicity
caffeine, cola and from increasing
chocolates. intracranial
pressure.
9. Instruct client in
signs/symptoms to 9. Promotes
report to physician knowledge and
such as headache compliance with
upon rising, treatment. Promotes
increased blood prompt detection
pressure, chest pain, and facilitates
shortness of breath, prompt intervention.
increased heart rate,
visual changes,
oedema, muscle
cramps and nausea
and vomiting.
REFERENCE
KOZIER B., ERB G., BERMAN A., LAKE R., 2008. Fundamentals of Nursing: concepts, process
and practise. Pearson Education Limited.
SANDRA L. UNDERHILL et al, 2007. Cardiac Nursing. 2nd ed p. 841-842. J.B Lippincott
Company.