Professional Documents
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School of Nursing
Submitted by:
Manglapus, Giana L.
BSN IV-A3
Review clients at risk as noted in Related Persons with acute or chronic conditions
Factors as well as individuals with may compromise circulation and place
conditions that stress the heart. excessive demands on the heart.
Monitor and record BP. Measure in both Comparison of pressures provides a more
arms and thighs three times, 3–5 min apart complete picture of vascular involvement
while patient is at rest, then sitting, then or scope of problem. Severe hypertension
standing for initial evaluation. Use correct is classified in the adult as a diastolic
cuff size and accurate technique. pressure elevation to 110 mmHg;
progressive diastolic readings above 120
mmHg are considered first accelerated,
then malignant (very severe). Systolic
hypertension also is an established risk
factor for cerebrovascular disease and
ischemic heart disease, when diastolic
pressure is elevated.
Note presence, quality of central and Bounding carotid, jugular, radial, and
peripheral pulses. femoral pulses may be observed and
palpated. Pulses in the legs and feet may
be diminished, reflecting effects of
vasoconstriction (increased systemic
vascular resistance [SVR]) and venous
congestion.
Auscultate heart tones and breath sounds. S4 heart sound is common in severely
hypertensive patients because of the
presence of atrial hypertrophy (increased
atrial volume and pressure). Development
of S3 indicates ventricular hypertrophy and
impaired functioning. Presence of
crackles, wheezes may indicate pulmonary
congestion secondary to developing or
chronic heart failure.
Observe skin color, moisture, temperature, Presence of pallor; cool, moist skin; and
and capillary refill time. delayed capillary refill time may be due to
peripheral vasoconstriction or reflect
cardiac decompensation and decreased
output.
Note dependent and general edema. May indicate heart failure, renal or
vascular impairment.
Maintain activity restrictions (bedrest or Lessens physical stress and tension that
chair rest); schedule periods of uninterrupted affect blood pressure and the course of
rest; assist patient with self-care activities as hypertension.
needed.
Provide comfort measures (back and neck Decreases discomfort and may reduce
massage, elevation of head). sympathetic stimulation.
Note presence of factors contributing to fatigue (age, Fatigue affects both the client’s actual and
frail, acute or chronic illness, heart perceived ability to participate in activities.
failure, hypothyroidism, cancer and cancer therapies).
Evaluate client’s actual and perceived limitations or Provides comparative baseline and provides
degree of deficit in light of usual status. information about needed education
and interventions regarding quality of life.
Assess the patient’s response to activity, noting pulse The stated parameters are helpful in assessing
rate more than 20 beats per min faster than resting physiological responses to the stress of activity
rate; marked increase in BP during and after activity and, if present, are indicators of overexertion.
(systolic pressure increase of 40 mm Hg or diastolic
pressure increase of 20 mm Hg); dyspnea or
chest pain; excessive fatigue and weakness;
diaphoresis; dizziness or syncope.
Encourage progressive activity and self-care when Gradual activity progression prevents a sudden
tolerated. Provide assistance as needed. increase in cardiac workload. Providing
assistance only as needed encourages
independence in performing activities.
Assess emotional and psychological factors affecting Stress or depression may be increasing the effects
the current situation. of an illness, or depression might be the result of
being forced into inactivity.
Problem: Risk for Electrolyte Imbalance (Hyperkalemia)
May be r/t: Treatment-related side effects or renal disease
Care Plan:
Nursing Interventions Rationale
Monitor heart rate and rhythm. Be aware that cardiac arrest Potassium excess depresses myocardial
can occur. conduction. Bradycardia can progress to
cardiac fibrillation and arrest.
Monitor respiratory rate and depth. Elevate the head of bed. Clients may hypoventilate and retain
carbon dioxide resulting in respiratory
acidosis. Muscular weakness can affect
respiratory muscles and lead to
respiratory complications.
Assess level of consciousness and neuromuscular function, Client is usually conscious and alert;
including sensation, strength, and movement. however, muscular paresthesia,
weakness, and flaccid paralysis may
occur.
Identify client at risk or the cause of the hyperkalemia such as Early identification and intervention can
excessive intake of potassium or decreased excretion. avoid complications.
Encourage frequent rest periods; assist with daily activities, as General muscle weakness decreases
indicated. activity tolerance.
Teach and assist the client with range-of-motion (ROM) Improves muscular tone and reduces
exercises, as tolerated. muscle cramps and pain.
Monitor laboratory results, such as serum potassium and Evaluate therapy needs and
arterial blood gasses, as indicated. effectiveness.
Loop diuretics such as bumetanide (bumex). Promotes renal clearance and potassium
excretion.
References:
Martin P. (2017). 10 Fluid And Electrolyte Imbalances Nursing Care Plans: Risk For
Electrolyte Imbalance (Hyperkalemia) retrieved August 12, 2018 from
https://nurseslabs.com/fluid-electrolyte-imbalances-nursing-care-plans/2/
Vera, M. (2013). 6 Hypertension Nursing Care Plans: Risk for Decreased Cardiac Output
retrieved August 12, 2018 from https://nurseslabs.com/6-hypertension-htn-nursing-care-plans/
Vera M. (2013). ). 6 Hypertension Nursing Care Plans: Activity Intolerance retrieved
August 12, 2018 from https://nurseslabs.com/6-hypertension-htn-nursing-care-plans/