BP: 180/60 mmHg

Acute Pain related to myocardial ischemia as

manifested by reports of chest pain and a BP of 180/60.
Acute Pain related to abdominal muscle spasm as
manifested by report of pain in epigastric region
• Obtain full description of pain from client including location,
intensity duration, characteristics, and radiation.
• Monitor vital signs, cardiac rhythm, respiratory rate and
hemodynamic response (BP and heart rate changes)
• Administer oxygen, as ordered
• Observe for associated symptoms, such as dyspnea, nausea,
Risk for decreased cardiac output related to fluid
vomiting, dizziness, palpitations, and desire to urinate.
imbalances affecting circulating volume,
• Observe or monitor signs and symptoms associated with
pain, such as BP, heartrate, temperature, color and moisture myocardial workload as evidenced by a bp
Imbalanced nutrition: less than body
of skin, restlessness, and ability to focus 180/60 of and hr of 54
requirement related to Inadequate food • Monitor urine albumin (protein) and
• Instruct patient to report pain immediately. Provide quiet
intake serum creatinine for renal failure.
environment, calm activities, and comfort measures. • Provide smaller meals and supplemental
Approach patient calmly and confidently. • Assess blood glucose levels before meals and at
snacks, as appropriate. bedtime.
• Instruct patient to do relaxation techniques like deep and
• Monitor exercise program and set limits on • Determine the blood glucose levels of the patient
slow breathing. Assist as needed.
physical activities. Chart activity and level of before exercising.
• Check vital signs before and after administration of opioid
work (pacing and so on). • Assess the pattern of physical activity.
medication • Identify the patient’s elimination patterns. • Report BP of more than 160 mm Hg (systolic).
• Make selective menu available, and allow Administer hypertensive as prescribed.
patient to control choices as much as possible. • Ensure patient eats a low protein diet
• Look for physical signs of poor nutritional • Instructed low fat, low calories and high fiber food
intake. Note amount and types of fluid intake. diet
Measure urine output accurately. • Encouraged to have regular check-up
• Weight, as indicated
• Review electrolyte and renal function test
results.