Nursing Diagnosis Risk for ineffective Tissue Perfusion - Hypertension
Risk for ineffective Tissue Perfusion: cerebral, renal, cardiac related to circulatory disorders
Purpose: uninterrupted circulation
Nursing Intervention:
a. Maintain bed rest; elevate the head of the bed
b. Assess blood pressure at admission in both arms; sleeping, sitting with arterial pressure monitoring if available.
c. Keep fluids and medications to order.
d. Observe the sudden hypotension.
e. Measure the input and output.
f. Monitor electrolytes, BUN, creatinine to order.
g. Ambulation according to ability; avoid fatigue.
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Expected results:
Patients demonstrating an improved tissue perfusion as indicated by: blood pressure within acceptable limits, no complaints of headaches, dizziness, laboratory values within normal limits.
Urine output of 30 mL / min
Vital signs are stable
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