Question

An elderly client presents to the Emergency Room with fatigue, shortness of breath, and jaw pain. The client states, "I just haven't been feeling well the last few days. My jaw is aching. I thought maybe I had a cavity, so I went to the dentist and they said nothing was wrong." During the admission assessment, the client reports substernal chest pain of 8/10 and is pale and diaphoretic. Vital signs: T: 97.6; P: 145; B/P: 89/45 mm/Hg; RR: 22; O2 Sat: 96% on 2 l via cannula.

• Identify the nurse’s priority action at this time and list at least 3 orders the nurse will anticipate from the provider.
• Based on the vital signs above, the nurse formulates a care plan for this client with a nursing diagnosis of decreased cardiac output. Identify one nursing goal for this client based on that nursing diagnosis and list 3 interventions to help the client meet that goal.

Answer 1

Diagnosis

Hypotension

If a blood pressure reading of 89/45 indicates Hypotension. Meaning your blood pressure is lower than the usual with values at a systolic (upper) value below 105 mmHg and a diastolic (lower) value of below 60 mmHg.

Identify the nurse’s priority action at this time and list at least 3 orders the nurse will anticipate from the provider.

What you must know as a nurse about a blood pressure of 89/45 initially.

The value of "very low" does not exist in the teachings of the WHO it is very usual to classify a blood pressure unter 105/60 as hypotension. If blood pressure measures 89/45 falls into this range.

some important orders a nurse can make

1. Remain hydrated is highly important at this point
2. Instruct patient to have salt rich foods
3. Warm and cold bath is recommended
4. Always stretch and extend
5. In the morning get out of bed really slow.
6. Advice to be active in sports and exercises

Identify one nursing goal for this client based on that nursing diagnosis and list 3 interventions to help the client meet that goal.

Cardiac output is the total output of blood pumped by the heart per minute. It is occured as a result of the heart beats, which is the number of beats per minute, and the stroke volume, it is the amount pumped in each beat.

CO = HR X SV. The cardiac output is usually measured in liters/minute.

Nursing Goal

- patient shows normal cardiac output as reported by pulse, blood pressure and rhythm are alligned in normal parameters; strength to undergo normal activities without the issues of any chest pain, syncope and dyspnea.

Some interventions

1. Strict records of intake and output chart including IV fluids
2. Maintain strict fluid restriction as per the order of doctor
3. Examine heart sounds frequently record rates and rhythm
4. Check for S3 and S4 sounds along with lung sounds
5. Not if chest pain and record the location, quality, severity and duration
6. Monitor Complete Blood Count
7. Strict monitoring of sodium level and serum creatinine.

These interventions could easily help the patient to meet the goals.