The nurse is planning care for an older patient with hypertension who recently fell in the home. Which assessment would the nurse plan for this patient?
1. Check serum sodium levels.
2. Check serum creatinine levels.
3. Check postural blood pressures.
4. Check blood pressure every 2 hours.
3
Rationale: Serum sodium levels would be used to assess renal function.
Rationale 2: Serum creatinine levels would be used to assess renal function.
Rationale 3: Since baroreceptors are less efficient with aging, postural hypotension is more likely to occur. Also, patients treated for hypertension could have an increase in sensitivity to the medications. Postural blood pressure assessment allows the nurse to prevent postural hypotension and falls.
Rationale 4: Every 2 hours is too frequent for assessments of a noncritical patient.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 5. Identify specific nursing interventions used with cardiovascular patients.
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