Published Jul 19, 2009
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.
The first intervention for your patient has to be safety. With this patients decrease in strength and mobility you want to make sure that assist this patient with toileting if there is no catheter in place, so one intervention could be placing this pt on the bedpan prn. Also since the pt is decreasing neurologically, then you want to implement frequent neuro checks throughout the shift. You also want to assess for the degree of weakness in the upper and lower extremities. This patient is an excellent candidate for a care plane because they are at risk for so many things like ineffective airway clearance, impaired physical mobility, disturbed sensory perception etc...Go to you care plan book for help. I used Mosbys and Gulanick/Meyers during my critical care med/surg clinicals, and they give all of the interventions along with the rationales. I truly hope this helps you...Try not to get too distressed..it will all be over soon...Good luck!
Daytonite, BSN, RN
i cannot tell if this is a real patient or this is a case scenario you were given to work on, but one thing is very clear. . .you are hung up on the medical diagnosis. a care plan is all about determining what the person's nursing problems (nursing diagnoses) are. to do that you have to assess the patient and isolate abnormal data. the only abnormal data you have posted is
your task is to figure out what nursing diagnoses any of the above are signs and symptoms of. just a word. "risk for" in a nursing diagnostic statement means the nursing problem is anticipatory, or not yet existent. if the patient has abnormal assessment data then something is happening and the risk is over and the problem has arrived.
i strongly suggest you look up "hypertension" and "hypertensive crisis" and read about them and their pathophysiology. also, look over this thread and how to do nursing diagnosis: https://allnurses.com/general-nursing-student/help-care-plans-286986.html - help with care plans. the nursing interventions for each diagnosis are based upon the aeb items that support and are the evidence proving that the nursing problem exists. the aeb items are the signs and symptoms (abnormal data from your assessment of the patient) of the nursing problem that you will develop specific treatment (nursing interventions) for. the reason you are having difficulty finding nursing interventions for this care plan is because you have not clearly determined what the abnormal data is yet. follow the nursing process.
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
Daytonite has it correct. You are a nurse. Not an MD. Your main concern is how to provide care for the client and the risk factors that may affect or change that care. You are not diagnosing or treating any disease.
Also, think about your wording and what you are saying (aside from NANDA). Since you are not an MD, it would be incorrect to infer that your patient has 'vascular resistance secondary to Hypertensive Crisis'. How can you determine that? Are you assuming that he has hyperthyroidism and is in a thyroid storm/toxicosis and thus his increased (not decreased) cardiac output thus triggered reflex resistance? Vascular resistance is a cause of HTN, but it doesn't make any sense to say that the vascular resistance was *caused by the HTN crisis*. If you were making a medical inference, you could reason that your patient has increased cardiac output/stroke volume due to Grave's toxicosis (hormone triggered HTN that can cause sinus tachy), which caused vascular resistance, which combined started a cycle that lead to a Hypertensive Crisis.
I'm simplifying of course. And I'm just a stupid Practical Nursing student.
But my point is that I agree with Daytonite and that you need to focus on what *nurses* diagnose (nurses are not junior MDs), and the NANDA list and format.
P.S. Daytonite gave you a good link. From what I have seen, this isn't really a homework question forum (assuming this is what your question is), so your best bet is to talk with your instructor if you are really stuck with the NANDA system. It is confusing to many people, especially if you are coming to nursing from another healthcare background. Nursing is its own entity with its own rules. :)
Thanks to each of you.... let's see if I can put this all back together...the right way.
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