1600: 58-year-old client with a history of hypertension and diabetes mellitus (type one) reports headaches and elevated blood pressure. The client reported the headaches started one day ago and have worsened. The client reports not taking his prescribed medications because he lost his health insurance. His prescribed antihypertensive medications were clonidine and enalapril. The client has a flushed appearance on exam, endorses a generalized headache, and blurred vision.
Oral temperature 99.5°F (37.5°C)
Pulse 114 bpm
Respirations 16
BP 207/124 mm Hg
Oxygen saturation 95% on room air
BUN 11 mg/dL (3.93 mmol/L) [10-20 mg/dL (3.6-7.1 mmol/L)]
Creatinine 1.5 mg/dL (132.6 mcmol/L) [0.6-1.2 mg/dL (53-106 mcmol/L)]
Capillary blood glucose 225 mg/dL (12.5 mmol/L) [70-110 mg/dL (4-6 mmol/L)]
- Nitroprusside via continuous infusion
- Timolol 0.25% to both eyes
➢ Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress.
Action to Take: Administer prescribed timolol ophthalmic | Obtain hourly blood glucose levels | Obtain a prescription for regular insulin infusion | Position the client Semi-fowler’s | Administer prescribed nitroprusside
Potential Conditions: Myocardial infarction | Hypertensive emergency | Migraine headache | Diabetic ketoacidosis | Angle Closure Glaucoma
Parameters to Monitor: Troponin | Blood glucose | Thiocyanate levels | Blood pressure | Intraocular pressure (IOP)
Action to Take: Administer prescribed timolol ophthalmic | Obtain hourly blood glucose levels | Obtain a prescription for regular insulin infusion | Position the client Semi-fowler’s | Administer prescribed nitroprusside
Parameters to Monitor: Troponin | Blood glucose | Thiocyanate levels | Blood pressure | Intraocular pressure (IOP)
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