Nursing Care Plan

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Medical Diagnoses: Ineffective tissue perfusion (cardiac, renal, cerebral). Decreased hemoglobin concentration in blood, exchange problems, impaired transport of oxygen and interruption of blood flow secondary to subarachnoid hemorrhage
Assessment Nursing DX/Clinical Problem Problem Client Goals/Desired Outcomes/Objectives Long Term: Client will verbalize knowledge of their treatment regimen, including appropriate exercise and medications, their actions and possible side effects by [date] at 16:00. Nursing Interventions/Actions/Orders and Rationale

Subjective: Daughter reported patient exhibited mood swings and periods of confusion. Client expressed she didnt want to move anymore than she has to. Hx of DM II, CAD Objective: Temp: 101.0 Basilar rales bilaterally Elevated BP (145/86) Elevated HR (110) Client is in atrial fibrillation w/ rapid ventricular response EKG findings of inferior infarction and left axis deviation Decreased grips/weakness on left side

Ineffective tissue perfusion (cardiac, renal, cerebral)

-Assess current level of knowledge r/t treatment regimen, exercise and medications. -Aggressively counsel the patient to stop smoking and refer to the physician for medications to support nicotine withdrawal and a smoking withdrawal program. There is a 45% smaller hyperemic vascular responsive in smokers than non-smokers (Noble, Voegeli, McClough, 2003). -Teach client the treatment regimen, exercise goals and plan, and medication regimen along with actions and side effects. All interventions to be evaluated [date], 16:00. -Monitor for s/s of heart failure and decreased cardiac output; listen to heart sounds, lung sounds; note symptoms. -If symptoms of renal failure, cardiac failure or another CVA occur, notify the physician immediately. -Monitor peripheral pulses. If there is a new onset of loss of pulses with bluish, purple or

R/T Decreased hemoglobin concentration in blood, exchange problems, impaired transport of oxygen and interruption of blood flow secondary to subarachnoid hemorrhage

Short Term: Client will demonstrate adequate tissue perfusion AEB blood pressure, pulse rate and rhythm within normal parameters for client; strong peripheral pulses, and ability to tolerate activity without

Decreased urine output (0 ml/10 hours) Elevated potassium level of 5.3 Elevated BUN (41) Elevated Creatinine (1.73) Post-CVA

AEB: Altered mental status, behavior changes, changes in papillary reactions, difficulty in swallowing, left side extremity weakness, right side hemiparesis, altered BP outside of acceptable parameters, oliguria (0 ml/10 hr), elevated BUN (41), elevated creatinine (1.73), dysrhythmias, altered respiratory rate (24).

dyspnea, syncope or chest pain, and increased urine output by [date] at 16:00.

black areas and extreme pain, notify the physician immediately. -Monitor neuro status frequently -Administer oxygen via nasal cannula to increase O2 to at least 92% as ordered

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