An older adult patient with HF is being discharged home on an ACE inhibitor and a loop diuretic
The patient's most recent vital signs prior to discharge include oxygen saturation of 93% on room air, heart rate of 81 beats per minute, and blood pressure of 94/59 mm Hg. When planning this patient's subsequent care, what nursing diagnosis should be identified?
A) Risk for ineffective tissue perfusion related to dysrhythmia
B) Risk for fluid volume excess related to medication regimen
C) Risk for ineffective breathing pattern related to hypoxia
D) Risk for falls related to hypotension
Ans: D
Feedback:
The combination of low BP, diuretic use, and ACE inhibitor use constitute a risk for falls. There is no evidence, or heightened risk, of dysrhythmia. The patient's medications create a risk for fluid deficit, not fluid excess. Hypoxia is a risk for all patients with HF, but this is not in evidence for this patient at this time.
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