cparr0623

Thanks to each of you.... let's see if I can put this all back together...the right way.

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.