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Decreaced cardiac output

Lahore School of Nursing University of Lahore MR # : UOL-M-012563-17 Age: 30yrs Sex: Male Ward: Emergency Ward Medical Diagnose: Hypertension Nursing Diagnosis: Decreased cardiac output Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation Subjective Data: The patient verbalized, ‘‘I am feeling lethargic, nauseated from last two to three hours even in sitting condition.’’ He came there on wheel chair Objective Data: A young male of 30 years of age patient came with the lethargic condition on the wheel chair. He was feeling lethargic, and some feelings of the fainting too. His cardiac output was low as evidenced by the vital signs. Vital signs: B.P: 190/120mmHg Pulse: 106/min Respiration: 20/min Temperature: 990F O2 saturation: 98% Weight: Normal Decreased Cardiac Output related to malignant hypertension as evidenced by decreased stroke and high blood pressure reading as 190/120mmHg. (NANDA nursing Diagnosis 2015-17) Short Term Planning: After 6 hours of nursing interventions, the client will have no elevation in blood pressure above normal limits and will maintain blood pressure within acceptable limits. Long Term Planning: After 5 days of nursing interventions, the client will maintain adequate cardiac output and cardiac index. Establish rapport with the patient. Monitor and record vital signs Monitor BP every1-2 hours, or every 5 minutes during active titration of vasoactive drugs. Encourage patient to decrease intake of caffeine, cola and chocolates. Monitor for sudden onset of chest pain. Observe skin color, temperature, capillary refill time and diaphoresis. Administer medicines as prescribed by the physician. Provide quiet and calm environment. Instruct client &family on fluid and diet requirement and restrictions of sodium. To gain the patient’s trust. To establish the baseline data. To monitor baseline data. (NANDA nursing Diagnosis 2015-17) May indicate cyanide toxicity from increasing intracranial pressure. May indicate dissecting aortic aneurysm. (NANDA nursing Diagnosis) Peripheral vasoconstriction may result in pale, cool, clammy skin ,with prolonged capillary refill time To promote wellness. To increase the relaxation. Restrictions can assist with decrease in fluid retention and hypertension, thereby improving cardiac output After my nursing intervention of three-four hours, the patient verbalized that he is now feeling well and has reduced blood pressure to 140/90mmHg. He is comfortable now. Reference: Nanda (2007).Nursing Diagnosis Book, NEW YORK, wellington publication house Juall carpenito, L-Moyet. (2010) Handbook of Nursing Diagnosis (13th ed) - Lippincott Williams & Wilkins. Mental Health Nursing (NUR321) 3