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Cues: Subjective/ Objective Background of The Disease Nursing Diagnosis Goal/ Objectives Intervention Rationale Evaluation
Cues: Subjective/ Objective Background of The Disease Nursing Diagnosis Goal/ Objectives Intervention Rationale Evaluation
Nursing diagnosis
Goal To demonstrate hemodynamic stability including blood pressure, cardiac output, renal perfusion/urine output, and peripheral pulses.
Independent: 1. Place patient in semifowlers position, and may elevate legs 20-30 degrees in shock situation 2. Monitor vital signs -to note response to activities/ interventions 3. Monitor cardiac rhythm continuously -to note effectiveness of medications and/or -decreases oxygen consumption and risk of decompression.
After 8 hours of nursing interventions the patient was able report decrease episodes of dyspnea, and angina. Dysarythmias were still evident when
Ventricular overload
O- difficulty of breathing -orthopnea -edema on both feet -decreased peripheral pulse -crackles Vital signs: RR -24 cpm
4. Assess urine output hourly or periodically and weigh the client daily noting total fluid
HR -121 bpm
hypertrophy
decrease episodes of
balance 5. Monitor rate of IV drugs closely, using infusion pumps as appropriate 6. Provide quiet and comfortable environment 7. Assist with or perform self-care activities for client -to limit activities that will decrease oxygen consumption 8. Provide information about testing procedures and dietary/fluid restrictions 9. Provide psychological support. Maintain a calm attitude but admit concerns if questioned by client -to promote client participation on the therapeutic regimen -honesty can be reassuring when so much activities and worry are apparent to the client. -to promote adequate rest. -to prevent bolus/overdose
activity tolerance and participates in activities that reduce cardiac workload. RR 22 cpm HR 112 bpm
dyspnea, angina and dysarythmia b. Demonstrate an increase in activity tolerance c. Verbalize knowledge of the disease process, individual risk factors and treatment plan d. Participate in activities that reduce workload of the heart.
Dependent: 1. Administer oxygen via nasal cannula or mask -to increase oxygen available for
as indicated
3. Administer analgesics