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NURSING CARE PALN OF Mrs RICHARD (CLINICAL

SCENARIO-3)

SUBMITTED TO, SUBMITTED BY,

Prof. Mrs.REGI PHILIP AXSA ALEX

HOD OF MSN 1st Year MSc NURSING

SJCON SJCON
SUBMITTED ON-31/5/2020
ANCHAL ANCHAL
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Nursing problems
 Increased respiratory rate

 Low blood pressure

 Decreased urine output

 Anxiety
Nursing diagnosis

 Ineffective breathing pattern related to respiratory distress as evidenced by increased respiratory rate 30brths /mt.

 Decreased cardiac output related to hypovolemic shock as evidenced by low BP.

 Deficient fluid volume related to failure of internal mechanism as evidenced by decreased urine output less than 60cc per hour, low BP.

 Anxiety related to change in health status as evidenced by verbalized anxiety

Nursing care plan.
Assessment Diagnosis Goal Planning Rationale Implementation Evaluation

Subjective data Ineffective Patient  Place patient with proper  A sitting

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Patient says breathing maintains body alignment for position
that “I have pattern related normal maximum breathing permits
difficulty to to respiratory breathing pattern. maximum lung
take breath” distress as pattern. excursion and
Objective data evidenced by chest
on observation increased expansion.
patient have respiratory rate  Encourage sustained deep  These
 shallow 30brths /mt. breaths by: techniques
breath • Using promotes deep
demonstration: inspiration,
 increased highlighting which increases
respiratory slow oxygenation
rate inhalation, and prevents
30brths /mt holding end atelectasis.
inspiration for Controlled
a few seconds, breathing
and passive methods may
exhalation also aid slow
• Utilizing respirations in
incentive patients who
spirometer are
• Requiring the tachypnoeic.
patient to Prolonged
yawn expiration
prevents air
trapping.
 Encourage diaphragmatic  This method
breathing for patients with relaxes muscles
chronic disease. and increases
 Evaluate the the patient’s
appropriateness of oxygen level.
inspiratory muscle training.  This training
improves
Assessment Diagnosis Goal Planning Rationale Implementation Evaluation
conscious
control of
Subjective data Decreased Patient  Assess the client’s HR  Sinus tachycardia
respiratory
muscles and
inspiratory
 Provide respiratory muscle
medications and oxygen, strength.
per doctor’s orders.  Beta-
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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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the low perfusion

state, acidosis, or
hypoxia, as well
as from side
effects of cardiac
medications used
to treat this
condition.
 Assess the central and  Pulses are weak,
peripheral pulses. with reduced
stroke volume
and cardiac
output.

 Assess capillary refill  Capillary refill is

time. slow and
sometimes
absent.
 Characteristics of
 Assess the respiratory a shock include
rate, rhythm and rapid, shallow
auscultate breath respirations and
sounds. adventitious
breath sounds
such as crackles
and wheezes.
 Monitor oxygen  Pulse oximetry is
saturation and arterial used in
blood gasses. measuring
oxygen
saturation. The
normal oxygen
saturation should
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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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lifesaving measures cardiogenic

according to shock. Depending
Advanced Cardiac Life on etiological
Support guidelines, as factors,
indicated. vasopressors,
inotropic agents,
antidysrhythmics,
or other
medications can
be used.

Assessment Diagnosis Goal Planning Rationale Implementation Evaluation

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Subjective data Deficient Fluid Patient  Monitor BP for  A common

Patient says Volume related maintains orthostatic changes manifestation of
that “I have to failure of normal urine (changes seen when fluid loss is
decreased urine internal output and changing from a postural
output” mechanism as normal BP. supine to a standing hypotension. The
Objective data evidenced by position). incidence
on observation decreased urine increases with
patient have output less than age. Note the
 decreased 60cc per following
urine output hour,low BP. orthostatic
less than hypotension
60cc per significances:
hour.  Greater than
 Low BP. 10 mm Hg:
circulating
blood volume
decreases by
20%.
 Greater than
20 to 30 mm
Hg drop:
circulating
blood volume
is decreased
by 40%.

 Assess the client’s HR,

BP, and pulse
pressure. Use direct
intra-arterial
monitoring as  Sinus tachycardia
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ordered. and increased

arterial BP are
seen in the early
stages to maintain
an adequate
cardiac output.
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
 Assess for changes in increase in HR.
the level of  Confusion,
consciousness. restlessness,
headache, and a
change in the level
of consciousness
may indicate an
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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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 Obtain a spun therapy.

hematocrit, and
reevaluate every 30
minutes to 4 hours,
depending on the
client’s ability.
 Hematocrit
decreased as
fluids are
administered
because of
dilution. As a
rule of thumb,
hematocrit
decreases 1%
per liter of
normal saline
solution or
lactated
Ringer’s used.
Any other
 Encourage oral fluid hematocrit
intake if able. decrease must
be evaluated
as an
indication of
continued
blood loss.
 The oral route
supports in
maintaining
fluid balance.
 Prepare to administer
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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.

Assessment Diagnosis Goal Planning Rationale Implementation Evaluation

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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.

 Explain all  Information helps

procedures reduce anxiety.
as Anxious clients
appropriate, unable to
keeping understand
explanations anything more
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basic. than simple, clear,

brief instructions.
 Maintain a  The staff’s anxiety
confident, may be easily
assured perceived by the
manner client. The client’s
while feeling of stability
interacting increases in a
with the calm and non-
client. Assure threatening
the client atmosphere. The
and presence of a
significant trusted person
others of may help the
close, client feel less
continuous threatened.
monitoring
that will
ensure
prompt
intervention.