Ms. Davenport is a 47 years old female and was admitted to the healthcare facility. Upon admission we conduct a systematic assessment. The nursing assistant took her vital signs and on documentation of her vital signs measurements shows that some of her results are not within the normal ranges. Nursing Care Plan
A 47 year-old-female complains of headache and numbness of her left hand. Vital signs: Temp 37.2˚c; Resps. 28/minute, BP 150/100mmHg, Pulse is weak upon palpation. She appears to be in anxious and shows signs of rib retraction and nasal flaring.
Nursing Diagnosis #1
Headache related to increased in cerebral vascular pressure
1. Assess blood pressure in both arms, using a cuff and proper techniques in measuring BP, Blood pressure measurement is more accurate when using the bell rather than the diaphragm of the stethoscope (Lockwood et al,2004.) 2. Minimize disruption and provide a quite environment by minimizing environment stimuli. Promotes relaxation 3. Eliminate vasoconstricting activities that may aggravate headache, e.g., straining at stool, prolonged coughing, bending over. This activities increases vasoconstriction accentuates the headache in the presence of increased cerebral vascular pressure. 4. Medical collaboration in providing analgesics. Reduces pain and decrease stimulation of the sympathetic nervous system. Evaluation:
The patient reports relieved of headache, Verbalize methods that provide relief and maintains blood pressure within an acceptable range.
Nursing Diagnosis #2
Ineffective tissue perfusion related to impaired circulation Planning/Intervention/Rationale
1. Observation of the skin color and temperature Skin pallor or mottling, cool or cold skin temperature, or an absent pulse can signal arterial obstruction, which is an emergency that requires immediate intervention. Rubor (reddish-blue color accompanied by dependency) indicates dilated or...
References: Jarvis, C., Forbes, H., & Watt, E., (2012). Jarvis Physical Examination and Health Assessments: Vital Signs (pp.128-163). Elsevier, Australia
Elliot, M., & Conventry, A. (2012). Critical care: the eight vital signs of patient monitoring, British Journal. 21(10), 621-625
Ineffective Tissue perfusion Nursing Diagnosis.[Web Log Post] Retrieved from http://nanda-nic-noc.blogspot.com/2013/03/
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