1. Changes in BP may indicate changes in patient's status requiring prompt attention 2.

decrease in cardiac output may result in changes in cardiac perfusion causing dysrhythmias. 3. it may decreases peripheral venous pooling that may be potentiated by vasodilators and prolonged sitting or standing. 4. caffeine is a cardiac stimulant and may adversely affect cardiacfunction. 5. Peripheral vaso constriction may result in pale, cool, clammy skin,with prolonged capillary refill. 6

.Auscultate heart tones. . administer medicines as prescribed by the

physician. 8. Instruct client &care givers/family on fluid and diet requirements and restrictions of sodium.9. instruct client and care giver/family on medications and their side effects.

Rationale: Evaluations re:

Short term goals:

After 6 hrs of nursing interventions, the client had no elevation in blood pressure above normal limits and will maintain blood pressure within acceptable limits. Goal was met. : Evaluation Re: Long Term Goal
After 5 days of nursing interventions, the client maintained an adequate cardiac output and cardiac goal was met