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Part A

Prior to clinical determine


potential complications
(aka collaborative
problems)
(Things that may go wrong
and require collaboration
with the physician)

Hypovolemic shock

For each potential complication list prior to clinical:


1. Monitoring activities for early detection.
2. Preventive measures, if appropriate, and their rationale
Activities/measures
1. Monitor mental status

Rationale
1. Restlessness, agitation, confusion
or any other mental changes- lack of
oxygen circulating

2. Assess VS

2. Significant decrease in BP,


rapid/weak pulses, rapid respirations,
diminished or absent peripheral
pulses- body trying to compensate

3. Monitor Urine output

3. Urine output less than 30ml hrRAAS system activated

1. Strict I&O

Fluid and electrolyte


imbalance

going in to coming out- pts hydration


2. Assess Lab results
3. Monitor daily weight

Hypoxia

1. To compare how much fluid is


status
2. Serum and urine osmolality, BUN,
serum sodium, H&H will be increased
3. Body weight changes reflect
changes in body fluid volume
1. Increased pulse and cyanosis are

1. Monitor respirations, pulse and skin


color.
2. Administer O2 if prescribed.
3.Elevate HOB.
4. Monitor O2 sats.
5. Monitor LOC.

indicators of hypoxia.
2. Higher concentration of O2 in
tissues and cells
3. postural breathing
4. if falls below 95% pt is hypoxic
5. change in mentation r/o hypoxia
(agitated, restless, lethargy and loss
of consciousness)

1. Monitor VS
Pain

2. Administer analgesics on a schedule


3. Assess the pain level on a 1-10
scale, the location, intensity, quality,
and timing.

1. Changes from baseline may


indicate pain (increase hear rate and
pulse)
2. To maintain the pain from
becoming to severe and not
manageable
3.To ensure pain is not cause of
another complication and the pain is
controlled

1. Asses for confirmed/suspected

Sepsis

infection and monitor patients at high

1. SEPSIS occurs from an infection

risk.

that went systemic.


Immunocompromised pts are at high

2. Monitor Temperature, heart rate,


respirations, WBC, and bands.

risk for septic shock.


2. An elevation in temp, HR, RR,

3. Asses lactate levels, creatinine,

WBC and bands >10% all fit the

bilirubin, platelets, and INR.

sepsis criteria when 2 or more are


present.
3. Lactate, Cr, and bilirubin >2.0,
platelets <100,000, INR >1.5 are
indicative of sepsis when 1 of these
are new to the pt.

1. Monitor VS

Hemorrhage

2. Check stool
3. Monitor H&H and pulse ox

4. Check skin color


5. LOC

ARDS

1. Assess pts ease of breathing.

1. Change of baseline initially all VS


increase. As bleeding continues B/P
decrease, Respirations & pulse
remain elevated due to
compensation.
2. To determine if there is internal
bleeding or occult blood
3. Low H&H and pulse ox can be
indicative of internal bleeding
because lack of RBC and oxygen
saturation.
4.Skin would be pallor, clammy, &
cool due to blood supply going to
vital organs
5. Agitated, restless, lethargy, & loss
of consciousness early sign of
hemorrhaging

1. Rapid onset of dyspnea is a

2. Monitor pulse and skin color

symptom of ARDS.

3. Assess breath sounds.

2. Tachycardia and central cyanosis

4. Monitor LOC.

are signs of
ARDS.
3. Crackles are an indicator of ARDS.
4. Altered sensorium, confusion are
indicators of ARDS.

Cardiac arrest

1. Obtain potassium levels


2. Monitor B/P

1.High k+ can cause cardiac arrest

3.Asses peripheral pulses

2. Hypotension from abnormal levels


of potassium.
3. Thready pulses from the delayed
electrical changes.

1.Listen to patients breath sounds.


2. Monitor patients temperature.

Hospital acquired
Pneumonia

1.Listen for crackles and wheezes.


2.Elevated temperature is indicative

3. Position patient in Semi-Fowlers.

of PNA.
3. Semi-Fowlers makes it easier to

4. Encourage patients to use IS,

breath.

perform Coughing and Deep Breathing

4. Promotes lung expansion and

and T&P.

systemic oxygenation of tissues.

5. Ambulate

5. Increases circulation and prevents

6. Administer O2 if prescribed.

pooling

7. Administer antibiotics if prescribed.

6. O2 helps with tissue perfusion.


7. ATB clears bacterial infections.

1. Monitor for chest pain


1. Sudden chest pain can be a sign

Pneumothorax

2. Listen to breath sounds

2. Shortness of breath can be a


symptom of pneumothorax and the

3. Assess position of tracheostomy

absence of sounds on the affected


side.
3. A deviated trach is a sign of a
tension pneumothorax.

1. Asses for confirmed/suspected


infection and monitor patients at high

1. SEPSIS occurs from an infection

risk.

that went systemic.

Sepsis

Immunocompromised pts are at high


2. Monitor Temperature, heart rate,
respirations, WBC, and bands.

risk for septic shock.


2. An elevation in temp, HR, RR,
WBC and bands >10% all fit the
sepsis criteria when 2 or more are
present.

3. Asses lactate levels, creatinine,

3. Lactate, Cr, and bilirubin >2.0,

bilirubin, platelets, and INR.

platelets <100,000, INR >1.5 are


indicative of sepsis when 1 of these
are new to the pt.