Trixia T.

Camporedondo 4AN2 Intensive Care Unit August 26-27, 2014

Assessment Diagnosis Inference Goal Nursing Intervention Rationale Evaluation

Subjective:

Patient is in ET and
unconscious.

Objective:
BP: 90/70
mmHg
RR: 28
breaths/min
PR:114 bpm
Weak
peripheral
pulses
Tachycardia
Oliguria
Narrowing
Pulses



Decreased cardiac
output related to
altered cardiac
structure.

Decreased
contractility

Decrease cardiac
output

Decreased blood
volume

Decreased coronary
artery perfusion

Decreased blood
supply

Hypoxia

Compensatory
mechanism
increased RR

Difficulty of
breathing


Endotracheal
Intubation with
Mechanical

After 15 minutes of
nursing
intervention the
patients vital signs
will be within
acceptable limit.



Obtain HR, RR,
and BP every
15 minutes to
evaluate the
patients
response to
therapy and
detect
cardiopulmon
ary
deterioration.

Auscultate
apical pulse.

Palpate
peripheral
pulses.






Monitor BP.




To establish
baseline.










Tachycardia is
usually present.

Decreased
cardia output
may be reflected
in diminished
radial, popliteal
dorsalis pedis
and posttibial
pulses.

Body may no
longer
compensate and
cause

After 15 minutes of
nursing
intervention the
patients vital signs
within acceptable
limit.









Trixia T. Camporedondo 4AN2 Intensive Care Unit August 26-27, 2014

Ventilator







Monitor urine
output.





Encourage
rest.





Provide quiet
environment
and avoid
stressful
situation.





Administer
medication as
ordered by
the physician.
hypotension.

Kidneys respond
to decreased
cardiac output
by retaining
water and
sodium.

Physical rest
should be
maintaining to
decrease the
oxygen demand
of the body.

Psychological
rest helps
reduce
emotional
stress, which can
produce
vasoconstriction,
elevating BP and
increase heart
rate.





Trixia T. Camporedondo 4AN2 Intensive Care Unit August 26-27, 2014