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DATE/TI ME

CUES Pale

NEED A

NURSING DIAGNOSIS De' eased #iss+e /# de' eased bl%%d

OBJECTIVES OF CARE A# #*e end %" $! 9 pa#ien# 7ill be able #%

NURSING INTERVENTIONS /. M%ni#% Vi#al Si-ns espe'iall! PR and CR. R. T% De#e $ine #*e se.e i#! %" #*e '%ndi#i%n

EVALUATION G%al Pa #iall! Me# A# #*e end %" $! 9 *%+ s span %" 'a e #*e pa#ien# 7as abl #% i$p %.e #iss+e pe "+si%n as e.iden'ed b!: a. (a $ s)in8 s#able .i#al si-n and palpable p+lses. b. T*e pa#ien# '*an-es p%si#i%n e.e ! #7% *%+ s8 s*e a.%ids dan-lin- %" "ee# 7*en

nailbeds. C Capilla ! T e"ill #i$e I %" & V se'%nds. I T (ea) pe ip*e a 2 l P+lse Cla$$! s)in S)in is '%%l #% #%+'* De' ease d ,e$%-l% bin Le.el /01-/dl E 3 E R S I C E P A T

pe "+si%n 4Pe ip*e al5 *%+ s span %" 'a e8 #*e .%l+$e se'%nda ! #% i$p %.e #iss+e den-+e ,e$% *a-i' pe "+si%n as e.iden'ed Fe.e . R. A $%s6+i#% 7*i'* 'a ies #*e den-+e .i +s is 'alled Aedes ae-!p#i. T*e said $%s6+i#% '%$es in '%n#a'# 7i#* a pe s%n and bi#es #*e pe s%n. T*e den-+e .i +s 7ill "l%7 bl%%d #* %+-* s# ea$ #*e and bl%%d %"#en b!: a. s#abili;ed .i#al si-ns8 7a $ s)in8 palpable pe ip*e al p+lses b. Ve bali;e +nde s#andin%" #*e '%ndi#i%n '. De$%ns# a#e be*a.i% s #% in' ease #iss+e pe "+si%n.

0. Meas+ e 'apilla ! e"ill R. to determine adequacy of systemic circulation 1. E.al+a#e "% si-ns %" in"e'#i%n espe'iall! 7*en i$$+ne s!s#e$ is '%$p %$ised R. as sepsis/septic shock can occur, resulting in decreased cardiac output/systemic perfusion with

des# %!s 7i#* den-+e

'%$p%nen#s. Pa#ien#s *as de' eased (BC8

T E R N

pla#ele# *ae$%-l%bin +sed %=!-en ,e$%-l%bin #*e e als% #%

< '%+n#. $eas+ e 'a !in'a ies

multiple organ involvement and critical consequences. &. Re.ie7 lab% a#% ! es+l#s for conditions R. hyperlipidemia, hypercholesterolemia, hypercoagulation) that can impair/occlude circulation. >. Palpa#e "% p esen'e and 6+ali#! %" p+lses. N%#e p+lselessness8 pa al!sis8 pa es#*esia8 pain8 and pall% R. suggestive of peripheral vascular disease ?. Inspe'# l%7e e=# e$i#ies "% s)in #e=#+ e 4e.-.8 a# %p*i'8 s*in!

sea#ed and a$b+la#es #% p %$%#e .en%+s e#+ n. G%al pa #iall! $e# be'a+se #*e pa#ien# "ailed #% .e bali;e +nde s#andin- in *e C%ndi#i%n.

,e$%-l%bin '%+n# is

'apa'i#! %" #*e bl%%d. %=!-en. T*e e"% e8 i" is de' eased de' eased *ae$%-l%bin8 #*e e is %=!-en #*a# ea'*es #*e di""e en# #iss+es %" #*e b%d!.

appea an'e58 la') %" *ai 8 d !/s'al!8 eddened s)in8 and s)in b ea)s/+l'e a#i%ns R. often accompany diminished peripheral circulation @. Re.ie7 lab% a#% ! s#+dies 4e.-.8 'l%##in#i$es8 ,b/,'#8 enal/'a dia' "+n'#i%n #es#s5 and dia-n%s#i' s#+dies R. to evaluate effectiveness of perfusion and determine degree of impairment 9. En'%+ a-e ea l! a$b+la#i%n 7*en p%ssible. R. Enhances venous return

A. Ele.a#e #*e le-s 7*en si##in-8 a.%idin- s*a p an-+la#i%n %" #*e *ips % )nees % +se %" )nee -a#'* %n bedB ele.a#e en#i e "%%# as indi'a#ed R. to enhance venous return/minimize edema formation. /C. De$%ns# a#e/en'%+ a-e +se %" ela=a#i%n a'#i.i#ies8 e=e 'ises/#e'*ni6+es R. to decrease tension level.