ASSESSMENT/ NURSING BACKGROUND GOAL AND NURSING RATIONALE EVALUATION
CUES DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTONS
Subjective Data: According to NOC NIC Goal was met as Decreased NANDA, manifested by: Subjective Cues: Cardiac Output Decrease Cardiac Cardiac Pump Hemodynamic related to Output define as Effectiveness Regulations • Mrs. SC, Altered preload: inadequate blood Short term goal 35 years old, decreased pumped by the Short term goal Check for any Decreased cerebral multigravida venous return as heart to meet the alterations in level perfusion and After 7 hours of evidenced by metabolic After 7 hours of of consciousness. hypoxia are nursing intervention • During elevated BP of demands of the nursing intervention reflected in the client was able the first trimester, 180/90 mmhg body the client will be able irritability, to: spotting was and presence of to: restlessness, and noted. edema difficulty concentrating. a. Determine and • In the a. Verbalize verbalized second trimester, knowledge of Monitor blood disease process, she didn’t the disease pressure of the Comparison of risk factors to experience any process and patient. Measure in pressures provides avoid severity, individual risk both arms or thighs a more complete and participate discomfort factors. three times,3- picture of vascular in activities that related to 5minutes apart while involvement or reduce blood pregnancy except Long term goal: patient is at rest, scope of the pressure. that she felt like After 1-2 days of then sitting, then problem her diet was nursing intervention standing for initial Long term goal: uncontrolled. She the client will be able evaluation After 1-2 days of was fond of to: nursing intervention the client was able eating chocolates, to: fruit shakes, and a. Display Review clients at Acute or chronic ice cream. hemodynamic risk as noted in conditions (e.g., stability Related Factors and multiple trauma, a. Display • On her Defining renal failure, hemodynamic third trimester, she was surprised Characteristics, as brainstem trauma, stability as upon knowing well as individuals spinal cord injuries evidenced by some deviations with conditions that at T8 or above, reduce blood from her vital stress the heart. alcohol or other pressure or drug abuse/ cardiac signs. She was overdose, and workload, troubled about pregnancy with management some discomforts hypertensive state) of edema and in certain areas of may compromise proteinuria her body. circulation and place excessive •According to her demands on the she was troubled heart. about the edema Note age and ethnic- that she related When in the supine experienced in cardiovascular position, pregnant considerations. women incur both feet and decreased vascular hands. return during the second and third trimesters, Objective Data: potentially compromising OB Score: cardiac output. G2T1P0A0L1
Vital Signs upon
admission: T: 37.4 Encourage Help reduce RR: 17 relaxation sympathetic P: 80 techniques, provide stimulation, BP: 180/90 calm, restful promotes UTZ surroundings, relaxation, reduce result: Abnormal minimize anxiety and cord coiling environmental conserve energy. activity or noise. Urinalysis Result: Sugar (-) Protein (++++) Maintain activity Reduces physical Ketones (-) restrictions stress and tension Blood (-) that affect blood Bilirubin (-) pressure and course WBC (0-2) of hypertension. Bacteria – none
Elevate edematous Elevation increases
Laboratory extremities, and venous return to the Report handle with care. heart and, in turn, Examination: 75 decreases edema. grams OGTT Edematous skin is more susceptible to injury.
Test Result Unit Normal Value Improve nutritional sodium-restricted FBS 5.34 Intake diet should be 2nd Hour BS 5.99 maintained while a patient is edematous and until proteinuria remits; during severe edema, careful and modest fluid restriction may be appropriate, but the patient must be monitored closely for excessive intravascular volume depletion.
Administer diuretics Diuretics promote
such as Thiazide excretion of water diuretics such as and electrolytes by hydrochlorothiazide the kidneys; these (Microzide) and agents are used to evaluate patient's treat heart failure or response. hepatic, renal, or pulmonary disease when sodium and water retention has resulted in edema or ascites.
Administer This agent is used
Immunosuppressive to supplement agents such as diuresis in patients prednisone and with edema; it evaluate patient’s increases oncotic response pressure and thereby promotes a fluid shift from interstitial tissues.