Question

i need a nursing care plan for this

Risk for injury related to physical changes as evidenced by elevated blood 160/100

Answer 1

Goal:

To maintain normal blood pressure

Subjective data:

Patient may complain of

• Severe headache
• Blurred vision
• Chest pain
• Palpitations
• Black out
• Blood tinged urine
• Nose bleed

Objective data:

• Elevated blood pressure
• Dyspnea
• Irregular heartbeat on auscultation
• Confused
• Dizzy,tired

Nursing intervention and Rationale:

• Monitor vital signs,to get the baseline data to plan for care
• Administer antihypertensive drugs to reduce the elevated blood pressure
• Follow a low sodium diet ,as high sodium intake can rise the blood pressure
• Cardiac markers,ECG,CBC ,Sr.Electrolytes can be helpful to assess the other factors associated with raised blood pressure
• Check BP on both arms because greater variation is an indicator of heart problem
• Monitor BP on lower limbs to rule out any peripheral vascular disease
• Explain all the procedure to patient,this reduces fear and ceases elevation of BP
• Provide a calm and quite environment to relax the patient

Evaluation:

The patient is a having a normal blood pressure