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Myocardial ischemia
Ventricular hypertrophy/rigidity
Possibly evidenced by
Desired Outcomes
Demonstrate stable cardiac rhythm and rate within patients normal range.
Nursing Interventions
Rationale
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.
Check laboratory data (cardiac markers,
complete blood cell count, electrolytes,
ABGs, blood urea nitrogen and creatinine, To identify contributing factors
cardiac enzymes, and cultures, such as
blood, wound or secretions).
Monitor and record BP. Measure in both
arms and thighs three times, 35 min
apart while patient is at rest, then sitting,
then standing for initial evaluation. Use
correct cuff size and accurate technique.
Nursing Interventions
Rationale
then malignant (very severe). Systolic
hypertension also is an established risk
factor for cerebrovascular disease and
ischemic heart disease, when diastolic
pressure is elevated.
Nursing Interventions
Rationale
Potassium-sparing
diuretics: spironolactone
(Aldactone); triamterene
(Dyrenium); amiloride (Midamor);
Nursing Interventions
Rationale
Calcium channel
antagonists: nifedipine
(Procardia); verapamil (Calan);
diltiazem (Cardizem); amlodipine
(Norvasc); isradipine (DynaCirc);
nicardipine (Cardene);
Adrenergic neuron
blockers: guanadrel (Hylorel);
guanethidine (Ismelin); reserpine
(Serpalan);
Direct-acting parenteral
vasodilators: diazoxide
(Hyperstat), nitroprusside
(Nitropress); labetalol
(Normodyne);
Angiotensin-converting
Nursing Interventions
enzyme (ACE) inhibitors:
captopril (Capoten); enalapril
(Vasotec); lisinopril (Zestril);
fosinopril (Monopril); ramipril
(Altace).
Angiotensin II
blockers: valsartan (Diovan),
guanethidine (Ismelin).
Rationale
Acute Pain
Acute Pain: Unpleasant sensory and emotional experience arising from actual or
potential tissue damage or described in terms of such damage; sudden or slow
onset of any intensity from mild to severe with anticipated or predictable end and a
duration of <6 months.
Nursing Diagnosis
May be related to
Possibly evidenced by
Reluctance to move head, rubbing head, avoidance of bright lights and noise,
wrinkled brow, clenched fists
Changes in appetite
Desired Outcomes
Nursing Interventions
Rationale
Provide or recommend
nonpharmacological measures for relief
of headache such as cool cloth to
forehead; back and neck rubs; quiet,
dimly lit room; relaxation techniques
(guided imagery, distraction); and
diversional activities.
Nursing Interventions
Rationale
membranes.
Coping, ineffective
May be related to
Poor nutrition
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Rationale
May be related to
Cultural preferences
Possibly evidenced by
Desired Outcomes
Nursing Interventions
Rationale
Nursing Interventions
Rationale
aggravate hypertension.
Identifies current
strengths and weaknesses in dietary
program. Aids in determining individual
need for adjustment and teaching.
Deficient Knowledge
Nursing Diagnosis
May be related to
Lack of knowledge/recall
Information misinterpretation
Cognitive limitation
Denial of diagnosis
Possibly evidenced by
Statement of misconception
Desired Outcomes
Identify drug side effects and possible complications that necessitate medical
attention.
Nursing Interventions
Rationale
Define and state the limits of desired BP. Provides basis for understanding
Explain hypertension and its effects on
elevations of BP, and clarifies frequently
Nursing Interventions
Rationale
Nursing Interventions
Rationale
medications.
Nursing Interventions
Rationale
Nursing Interventions
Rationale