Create nursing diagnoses for the following head-to-assessments:
1a.) Vital Signs: BP 167/100 mmHg, Resp. 22 breaths/min, SpO2 88%, Temp. 99° F, HR 113
1b.) Neurological: Headache not resolved with acetaminophen. DTR brisk, hyper-reflexive with clonus graded to +4. Blurred vision with spots.
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1c.)Cardiovascular: Dx of pre-eclampsia (BP of 167/100 mmHg). Heart rate and rhythm are regular without presence of murmurs. Tachycardia present. IV site has no redness, swelling, infiltration, bleeding or drainage. Dressing is dry and intact. |
NURSING DIAGNOSIS
1a) Activity intolerance related to imbalanced oxygen supply and demand as evidenced by heart rate 113beats/min, Spo2 88% Blood pressure 167/100mmHg
1b) Acute pain, headache related to increased cerebral vascular pressure as evidenced by verbal report of headache, blurred vision with spots, stiffnes of neck 4+
1c) Risk for decreased cardiac output related to increased peripheral vascular resistance
Create nursing diagnoses for the following head-to-assessments: 1a.) Vital Signs: BP 167/100 mmHg, Resp. 22 breaths/min,...