Hypertension is a risk factor for...

Hypertension is a risk factor for...

1. Fall Risk

   • Nursing assessments: Client fatigued upon exertion ; Pain in legs can alter gait ; BP was elevated d/t Hx HTN (132/72 , 160-86) ; potential CHF ; medications may pose as fall risk ; Hx Anemia
   • Nursing Interventions: Implement bed alarm ; Assistive 1 w/ walker ; Monitor BP levels ; pain assessment ;
   • No Labs/Procedures conducted

2. Acute Kidney Disease

   • Labs/Procedures: BUN- 58 (High) ; Creatinine 1.79 (High) ; GFR 43 (Low) ; UA- Hgb 1+, Protein 100 (2+)
   • Nursing Assessments: Chronic lower back pain radiating to lower extremities (fluctuated between 6,7,8) ; Current everyday light smoker ; Does not engage in exercise ; No incontinence ; Urine elimination 395 mL in urinal (no cloudiness, burning sensation, or discomfort ; No tachycardia with pain 72 and 78 bpm ; No tachypnea with pain 16 & 16 ; Blood pressure was 132/72 and 160/86 ; Urine Analysis reveals Hgb 1+, Protein 100 (2+)
   • Nursing Interventions: Ceftriaxone for UTI ; Nephrologist consultation ; Monitor Blood pressures (132/72 ; 160/86) Auscultate Heart sounds (regular) ; Breath sounds (normal, nonlabored even with pain ; Administer medications as prescribed (hydralazine, carvedilol) ; Administer percocets as ordered for pain manangement ; Created makeshift heating pad with warm towels in a bag for nonpharmocologic pain relief measures

3. Chronic Heart Failure

   • Labs and Procedures for potential CHF: BNP- 4595 ; Cardiac Catheterization ; Chest XR ; EF (40%); Troponin (-); EKG- left ventricular hypertrophy ; TE- Mild Mitral Regurgitation ; CT of chest/abdomen - enflamed lymph nodes
   • Nursing Interventions: Keep client NPO for procedures ; Assess gag reflex after procedure ; Maintain 2G sodium diet ; Install bed alarm ; Maintain Fall risk protocols ; Administer medications as prescribed ; Assess for edema ; Assess pedal/peripheral pulses ; Assistive 1 with walker ; Provide mouth swabs and lip moisturizer ; teach patients about CHF
   • Assessments: Client is fatigued upon exertion (could be d/t pain in lower back and legs ; HR- 72, 78 ; Spo2- 95, 99 ; BP- 132/72, 160/86 ; MAP 84, 113 ; Gait- +1 Assist ; Heart sounds normal ; Lung sounds normal ; Hendrichs score-2 ; EF- 40% ; Cap refill- <2 seconds ; pedal/peripheral pulses- normal, palpable ; dry mucous membranes d/t NPO status ; reports chest pain ; Hx cardiomyopathy

4. Mitral Valve Regurgitation

   • Labs and Procedures: BNP- 4595 ; Cardiac Catheterization ; Transesophageal Echocardiogram ; Troponin (-) ;
   • Nursing Assessments: Client fatigued upon exertion ; HR WNL ; Lung sounds WNL ; Peripheral/Pedal pulses WNL ; mucous membranes were dry d/t NPO status ; reports chest pain ; TE results revealed mild regurgitation
   • Nursing Interventions: Prepare client for TE ; Prepare client for Cardiac Catheterization ; Keep client NPO ; Assess gag reflex after TE procedure ; Assess for fluid in lungs ; Provide client mouth swabs and lip moisturizer