Nursing Care Paln of Mrs Richard (Clinical Scenario-3)
Nursing Care Paln of Mrs Richard (Clinical Scenario-3)
Nursing Care Paln of Mrs Richard (Clinical Scenario-3)
SJCON SJCON
SUBMITTED ON-31/5/2020
ANCHAL ANCHAL
2
Nursing problems
Increased respiratory rate
Anxiety
Nursing diagnosis
Ineffective breathing pattern related to respiratory distress as evidenced by increased respiratory rate 30brths /mt.
Deficient fluid volume related to failure of internal mechanism as evidenced by decreased urine output less than 60cc per hour, low BP.
Patient says cardiac output maintains and BP, including and increased
that “I feel related to normal cardiac peripheral pulses. Use arterial BP are
light- hypovolemic output. direct intra-arterial seen in the early
headedness” shock as monitoring as stages to
Objective data evidenced by ordered. maintain an
on observation low BP. adequate cardiac
patient have output.
low BP Hypotension
happens as
condition
deteriorates.
Vasoconstriction
may lead to
unreliable blood
pressure. Pulse
pressure (systolic
minus diastolic)
decreases in
shock. Older
client have
reduced
response to
catecholamines;
thus their
response to
decreased
cardiac output
may be blunted,
with less increase
in HR.
Cardiac
Assess the client’s dysrhythmias
ECG for dysrhythmias. may occur from
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be maintained at
90% or higher. As
shock progresses,
aerobic
metabolism stops
and lactic
acidosis occurs,
resulting in the
increased level of
carbon dioxide
and decreasing
Monitor the client’s pH.
central venous CVP provides
pressure (CVP), information on
pulmonary artery filling pressures
diastolic pressure of the right side
(PADP), pulmonary of the heart;
capillary wedge pulmonary artery
pressure, and cardiac diastolic pressure
output/cardiac index. and pulmonary
capillary wedge
pressure reflect
left-sided fluid
volumes. Cardiac
output provides
an objective
number to guide
Assess for any therapy.
changes in the level of Restlessness and
consciousness. anxiety are early
signs of cerebral
hypoxia while
confusion and
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loss of
consciousness
occur in the later
stages. Older
clients are
especially
susceptible to
reduced
perfusion to vital
Assess urine output. organs.
The renal system
compensates for
low BP by
retaining water.
Oliguria is a
classic sign of
inadequate renal
perfusion from
reduced cardiac
Assess skin color, output.
temperature, and Cool, pale,
moisture. clammy skin is
secondary to a
compensatory
increase in
sympathetic
nervous system
stimulation and
low cardiac
Provide electrolyte output and
replacement as desaturation.
prescribed.
Electrolyte
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imbalance may
cause
dysrhythmias or
other
pathological
Administer fluid states.
replacement therapy
as prescribed. Maintaining an
adequate
circulating blood
If possible, use a fluid volume is a
warmer or rapid fluid priority.
infuser. Fluid warmers
keep core
temperature.
Infusing cold
blood is
associated with
myocardial
dysrhythmias and
paradoxical
hypotension.
Macropore
filtering IV
devices should
also be used to
remove small
If the client’s clothes and
condition debris.
progressively Shock
deteriorates, initiate unresponsive to
cardiopulmonary fluid replacement
resuscitation or other can worsen to
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impending
hypovolemic
shock.
Monitor for possible Sources of
sources of fluid loss. fluid loss may
include
diarrhea,
vomiting,
wound
drainage,
severe blood
loss, profuse
diaphoresis,
high fever,
polyuria,
Assess the client’s skin burns, and
turgor and mucous trauma.
membranes for signs
of dehydration. Decreased
skin turgor is a
late sign of
dehydration.
It occurs
because of
Monitor the client’s loss of
intake and output. interstitial
fluid.
Accurate
measurement
is important in
detecting
negative fluid
balance and
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guide therapy.
Concentrated
urine denotes
a fluid deficit.
Monitor the client’s
central venous CVP provides
pressure (CVP), information
pulmonary artery on filling
diastolic pressure pressures of
(PADP), pulmonary the right side
of the heart;
capillary wedge
pulmonary
pressure, and cardiac
artery
output/cardiac index. diastolic
pressure and
pulmonary
capillary
wedge
pressure
reflect left-
sided fluid
volumes.
Cardiac
Monitor coagulation output
studies, including INR, provides an
prothrombin time, objective
partial thromboplastin number to
time, fibrinogen, fibrin guide therapy.
split products, and Specific
platelet count as deficiencies
ordered. guide
treatment
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a bolus of 1 to 2 L of IV
fluids as ordered. Use
crystalloid solutions
for adequate fluid and The client’s
electrolyte balance. response to
treatment
relies on the
extent of the
blood loss. If
blood loss is
mild (15%),
the expected
response is a
rapid return to
normal BP. If
the IV fluids
are slowed,
the client
remains
normotensive.
If the client
has lost 20%
to 40% of
circulating
blood volume
or has
continued
uncontrolled
bleeding, a
fluid bolus
may produce
normotension
, but if fluids
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are slowed
after the
bolus, BP will
deteriorate.
Extreme
caution is
indicated in
fluid
replacement
in older
clients.
Aggressive
therapy may
precipitate left
Initiate IV therapy ventricular
dysfunction
Start two shorter, large- and
bore peripheral IV lines. pulmonary
edema.
Maintaining
an adequate
circulating
blood volume
is a priority.
The amount of
fluid infused is
usually more
important
than the type
of fluid
(crystalloid,
colloid,
blood). The
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amount of
volume that
can be infused
is inversely
affected by
the length of
the IV
catheter; it is
best to use
large-bore
catheters.
Subjective data Anxiety related Patient attains Assess Anxiety and ways
Patient says that to change in reduced level of previous of decreasing
“I am worried health status as anxiety. coping perceived anxiety
about my evidenced by mechanism are highly
condition” verbalized used. individualized.
Objective data anxiety. Interventions are
on observation most effective
patient have when they are
aggitation consistent with
the client’s
established coping
pattern. However,
in the acute care
setting these
techniques may
no longer be
feasible.
Assess the Shock can result in
client’s level an acute life-
of anxiety. threatening
situation that will
produce high
levels of anxiety in
the client as well
as in significant
others.
Acknowledge Acknowledgement
an of the client’s
awareness of feelings validates
the client’s the client’s
anxiety. feelings and
communicates
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acceptance of
those feelings.
Encourage Talking about
the client to anxiety-producing
verbalized situations and
his or her anxious feelings
feelings. can help the client
perceive the
situation in a less
threatening
manner.
Reduce Anxiety may
unnecessary escalate with
external excessive
stimuli by conversation,
maintaining noise, and
a quite equipment
environment. around the client.
If medical
equipment is
a source of
anxiety,
consider
providing
sedation to
the client.