IX.

Prioritized List of Nursing Problems Date 8am 1-6-2011 Nursing Problems Identified Risk for decreased cardiac output related to increased vascular resistance due to hypertension Cues -BP- 170/100 -weakness -fatigue -shortness of breath Justification

8am 1-6-2012

Acute pain related to disruption of skin due to post operative

8am 1-6-2012

Excess fluid volume related to fluid and sodium retention as evidenced by localized edema

Hypertension increases the workload of the heart, increasing oxygen demand and coronary blood flow. The increased workload also causes hypertrophy of the blood flow. -Presence of pain The bodys response Pain Scale: to pain is a complex -Numeric: 6 process rather than a -Descriptive: specific action. It has moderate both physiologic and -Observed evidence psychosocial aspects. of pain Initially the -Protective gestures sympathetic nervous -Expressive behavior system responds, - Elevated blood resulting in the fight pressure or flight response -Client appears with a noticeable restless increase in pulse and blood pressure. -Presence of edema in Both intravascular the lower extremities and interstitial spaces -Specific gravity have an increased changes water and sodium -Altered electrolytes, content. Excess hgb and Hct interstitial fluid is -wt.: 41.5 known as edema. High quantities of sodium consumption can lead to an electrolyte imbalance, causing hypertension or edema. Edema, known as water retention, occurs when you consume

large amounts of sodium relative to your water intake.