Medical-surgical Nursing Demystified

CHAPTER 1 Cardiovascular System^35

• High Fowler’s position to ease breathing and enhance diaphragmatic
  excursion.


• Supplemental oxygen to meet increased demand of myocardium.


• Low-sodium diet to prevent additional fluid retention.

NURSING DIAGNOSES

• Impaired gas exchange


• Decreased cardiac output


• Excess fluid volume

NURSING INTERVENTION

• Monitor vital signs and look for changes.


• Record fluid intake and output—weigh daily to assess for fluid overload.


• Position patient in semi-Fowler’s position to ease breathing.


• Administer oxygen as ordered because it helps to decrease workload of heart.


• Tell the patient:
  
  
  • Eat foods low in sodium to avoid fluid retention. (For these patients, there
    is no such thing as “low-salt” cold cuts.)
  
  
  • Raise legs when sitting to lessen dependent edema.
  
  
  • Call the physician, nurse practitioner, or physician assistant if experienc-
    ing fluid retention, such as a weight gain of several pounds in 1 to 2 days.
  
  
  
  

Hypertension (HTN)

WHAT WENT WRONG?

Pressure inside blood vessels exceeds 140 mmHg systolic and 90 mmHg diastolic
on more than one occasion resulting from a primary disease or no known cause.
These are the classifications of hypertension:

• Normal <120 mmHg systolic / <80 mmHg diastolic


• Prehypertension: 120–139 mmHg systolic / 80–89 mmHg diastolic


• Stage 1 hypertension: 140–159 mmHg systolic / 90–99 mmHg diastolic

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