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NCP_Hypertension

NCP_Hypertension

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Published by Jet Bautista

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Categories:Types, School Work
Published by: Jet Bautista on Jan 03, 2011
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01/22/2012

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ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION

EVALUATION

BAUTISTA, Jesther Rowen, SN IV

SUBJECTIVE: (entubated) OBJECTIVE: - Lethargy - Elevated BUN/creatinine ratio (22mg/dl: 1.5mg/dl) - Decreased Urine Output (<30 ml /hr) - Mottling skin - Peripheral edema - Vital signs as follows: CR of 86 bpm BP of 160/60 mmHg RR of 24 cpm

Ineffective Tissue Perfusion secondary to disease process (Chronic Kidney Disease) as manifested by elevated blood pressure

At the end of the shift, INDEPENDENT: the patient will maintain optimal tissue perfusion - Monitor quality of all pulses. to vital organs, as evidenced by strong peripheral pulses, alert LOC, and the reduction of Blood pressure from 160/60 to 140/60 - Maintain optimal cardiac output. mmHg. prevent or minimize unpleasant odor or sights

RATIONALE: Assessment is needed for ongoing comparisons; loss of peripheral pulses must be reported or treated immediately. This ensures adequate perfusion of vital organs. Support may be required to facilitate peripheral circulation (e.g., elevation of affected limb, antiembolism devices). Exercise prevents venous stasis.

Goal met. At the end of the shift, the patient maintained optimal tissue perfusion to vital organs, as evidenced by strong peripheral pulses, alert LOC, and the reduction of Blood pressure from 160/60 to 140/60 mmHg.

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Do passive range-ofmotion (ROM) exercises to unaffected extremity every 2 to 4 hours. Keep cannulated extremity still. Use soft restraints or arm boards as needed. Administer oxygen as needed.

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Movement may cause trauma to artery.

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This saturates circulating hemoglobin and increases the effectiveness of blood that is reaching the ischemic tissues. This promotes optimal

BAUTISTA, Jesther Rowen, SN IV

Position properly.

lung ventilation and perfusion. The patient will experience optimal lung expansion in upright position. DEPENDENT: Administer antihypertensive as ordered. Lowers blood pressure by selectively stimulating receptors in the brain that monitor catecholamine levels in the blood. These receptors close a feedback loop that begins with descending sympathetic nerves from the brain that control the production of catecholamines (epinephrine, also known as adrenaline, and norepinephrine) in the adrenal medulla.

BAUTISTA, Jesther Rowen, SN IV

BAUTISTA, Jesther Rowen, SN IV

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