Nursing Students General Students
Published Aug 28, 2008
deanikins211
41 Posts
We are assigned as ER nurses.
Pt came in due to chest pain (9/10) ,positioning pt at supine position aggrevates the pain as reported by the SO. Pt also is nauseated. PT's vital signs are bp 150/100 t=37.5 RR=28 and P=68. (pulse is weak). ECG was taken but it really shows that pt really has a heart problem by just seeing the pqrst pattern. Our clinical instructor told us that pt is at risk for MI although there is no physical exam results yet.
My problem is: Hypertension
Diagnosis is : Risk for decreased cardiac output related to increased vascular resistance.
(are these properly stated?) (I think i should not use "secondary to" since there is no actual diagnosis yet( results)
pharmgirl
446 Posts
I am a complete novice at this since only started school 2 weeks ago. So, I'm going to ask a question continued on yours if you don't mind so I can learn too. Maybe if we're lucky Daytonite will chime in..LOL. At the end of " increased vascular resistance" should there be "as manifested by" or "evidenced by"????
Another question, if BP is 150/100 is that not considered hypertension? or still "risk of" ?
150/100 is already considered as hypertension. normal blood pressure is 120/80 for adults. In fact based on what i have observed , the patient already exprienced blurring of vision which is one of the signs of hypertension. And for the diagnosis, you can use secondary to in order to have complete diagnosis and as evidenced to in order to prove your diagnosis. BUT CORRECT ME IF IM WRONG. Im still very slow at making nursing diagnosis.
Daytonite, BSN, RN
1 Article; 14,604 Posts
pt came in due to chest pain (9/10) ,positioning pt at supine position aggrevates the pain as reported by the so. pt also is nauseated. pt's vital signs are bp 150/100 t=37.5 rr=28 and p=68. (pulse is weak). ecg was taken but it really shows that pt really has a heart problem by just seeing the pqrst pattern. our clinical instructor told us that pt is at risk for mi although there is no physical exam results yet.
NurseJeanB
453 Posts
Thanks Daytonite that makes a lot of sense. I also wanted to ask about the RR=28, that is abnormally high right? Of course that could be related to insufficient cardiac output, but I was just curious because I didn't see anyone mention it.
I also wanted to ask about the RR=28, that is abnormally high right? Of course that could be related to insufficient cardiac output, but I was just curious because I didn't see anyone mention it.
It is slightly high. With Decreased Cardiac Output you are looking for signs and symptoms of electrical failure in the heart (arrhythmias). congestive failure, or heart ischemia. You really are looking more for dyspnea, orthopnea and/or shortness of breath and that was not mentioned by deanikins211. I thought it safer to go with it being a symptom of Anxiety. However, symptoms can always worsen as a condition deteriorates. If respirations become labored then they become symptomatic of Decreased Cardiac Output as the heart goes under stress.