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Interventions >Monitor vital signs; palpate peripheral pulses, and note capillary refill. Evaluate changes in mentation.
Rationale >Indicators of adequacy of systemic perfusion, fluid/blood needs, and developing complications.
> Assess for abnormal heart and lung sounds. > Patients with renal failure are most often hypertensive, which is attributable to excess fluid and the initiation of the rennin-angiotensin mechanism. >Turn patient and encourage frequent coughing and deep- > Prevents stasis of secretions and breathing exercises. respiratory complications. > Prevents stasis of secretions and respiratory complications. >Promotes lung expansion/minimizes atelectasis. > Assist the patient in assuming a high Fowlers position. > Allows for better chest expansion, thereby improving pulmonary capacity. > Give oxygen as indicated by patient symptoms, oxygen > Makes more oxygen available saturation and ABGs. for gas exchange, assisting to alleviate signs of hypoxia and subsequent activity intolerance. References: >http://nurseslabs.com/congestive- References: heart-failure-av-block-nursing>http://nurseslabs.com/congestivecare-plans/ heart-failure-av-block-nursing-care>http://nurseslabs.com/nandaplans/ nursing-diagnosis-list/ >http://nurseslabs.com/nanda>http://nurseslabs.com/ineffective- nursing-diagnosis-list/ tissue-perfusion-hysterectomy>http://nurseslabs.com/ineffectivenursing-care-plans/ tissue-perfusion-hysterectomynursing-care-plans/