Hi, another nursing student needing help with a care plan here.
My patient was admitted with Hypertensive crisis (BP 236/117). Over a 24 hour period, the patient has had a reduction in strength and mobility on the right side. Very drowsy and disoriented. Answers "yes" to any questios. A CVA/Stroke is apparent, but there has been no medical diagnosis for a stroke. I am unsure how to proceed.
I am having difficulty determining the nursing diagnoses for this patient. I have searched the the other posts, but I have not found anything specific for Hypertesive Crisis. What is the number one and two? What are the specific interventions for a patient that cannot understand or assist?
How do I word these according to NANDA?
Risk for decreased Cardiac Output R/T Increased Vascular resistance secondary to Hypertensive Crisis
Risk for Ventricular Hypertrophy R/T Increased Vascular resistance secondary to Hypertensive Crisis
Risk for Cerebrovascular Accident/Stroke (Hemorrhagic) R/T to Hypertensive Crisis
Risk for Nutrition Imbalance: Less than body requirements R/T Poor Intake
Risk for Impaired Skin Integrity
I am not fond of these care plans, but I can usually struggle through them. This Hypertensive Crisis has been difficult for me to diagnose and provide interventions.. Any help is greatly appreciated.