Reason for admission:
High blood pressure
STUDENT: Jeannette Sutton PATIENT INITIALS: HPT ROOM #_____ Nursing Diagnosis:
Risk for imbalanced fluid volume r/t decreased sodium
level AEB patient taking hydrochlorothiazide.
Thiazide drugs promote excretion of Na, CL, K and water.
First time pt will be taking this drug.
STG: Pt will maintain sodium levels of 135-145 by 1700hrs after taking initial dose this morning. Interventions:
1. Administer medication as prescribed in the morning.
RATIONAL: medication is going to increase output which may cause the depletion of electrolytes. We will be able to see the change in Na by 1700hrs. 2. Monitor strict in & out put of fluids.
RATIONAL: to prevent dehydration and depletion of electrolytes. 3. Assess neuromuscular and LOC every 4-6 hrs.
RATIONAL: low sodium will causes the pt to have muscle cramping, weakness, and fatigue. Teach pt adequate nutritional intake.
RATIONAL: Eating the right foods will help the medication regime and disease process. #2
Knowledge deficit r/ disease process AEB pt newly
diagnosed with high blood pressure and states not knowing
how to modify lifestyle.
Pt diagnosed with high blood pressure.
Pt stating doesn’t know how to modify lifestyle.
STG: Pt will verbalize 3things that will help him manage disease process by 1700hrs today. Interventions:
1. Teach pt nutritional goals ie low in fat and cholesterol, low in salt; importance of exercise, and smoking cessation. RATIONAL: decrease risk of CHD
2. Instruct patient to take medication at the same time each day and not to stop taking it. RATIONAL: To prevent rebound hypertension.
3. Monitor and teach daily weigh ins.
RATIONAL: A wt gain of 2lbs or more in one day can be an indicator of fluid retention and must be addressed to physician. 4. Assess blood pressure and teach patient how to adequately take weekly blood pressure. RATIONAL:...