Question

R.A.'s vital signs on admission are T 36.5° C (97.7° F), P 118 regular and bounding. R 32 and labored, BP 160/100, with a pulse oximetry reading of 90% on room air. Alert and oriented to person, place, time and event. Denies pain Moves all extremities easily but requires assistance with ADLS, Becomes short of breath on exertion. He has fine crackles throughout all lung fields and has a moist, nonproductive cough, Bowel sounds active in all four quadrants. Last bowel movement was a formed brown stool yesterday. His skin is warm, dry, and slightly pale. He has 3+ pitting edema in lower extremities. Bilateral dorsalis pedis and posterior tibial pulses are diminished Complains of being tired all of the time and barely having enough energy to sit up sometimes. Waistband and shoes seem tight

what is the primary and secondary nursing diagnosis?

Answer 1

Primary nursing diagnosis

Impaired cardiac tissue perfusion related to hypertension as evidenced by BP of 160/ 100

Secondary diagnosis

Impaired gas exchange related to ventilation perfusion inequality as evidenced by spo2 - 90%

Thank you