ASSESSMENT NURSING EXPECTED IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS OUTCOME
SUBJECTIVE DATA: Ineffective tissue At the end of the shift, the 1.Assess the 1.Failure to produce Met.
(Patient can’t perfusion related to patient will have normal cardiovascular status. enough cardiac output At the end of the shift, the
communicate verbally: inadequate blood vital signs and maintain while maintaining patient had normal vital
tracheostomized) pressure, poorly peripheral pulses and complete peripheral signs and maintain
oxygenated blood and capillary refill time in resistance is known as peripheral pulses and
decreased hemoglobin as acceptable limits. cardiogenic shock. capillary refill time in
evidenced by Besides hypotension, it acceptable limits.
hypotension, weak can present as a weak
peripheral pulses, pulse, tachypnea,
tachycardia, tachycardia, and loss of
dysrhythmias, decreased consciousness
oxygen saturation,
tachypnea and
generalized body
weakness.
OBJECTIVE DATA: 2. Assess the patient’s 2. Central cyanosis occurs
T-35.9 C skin color and capillary from seriously impaired
PR- 96bpm refill. pulmonary function.
RR-30bpm Peripheral cyanosis
BP-93/47mmHg (post indicates vasoconstriction
bolus infusion from or obstructed blood flow.
ward)
02 sat- 96% (2lpm 02 3. Monitor intake and 3. A lack of blood
supplement via output. pressure and blood flow
thermovent) can affect kidney function
GCS- 9/10 resulting in reduced urine
(+) feeble pulses output. Closely monitor
E-spontaneous and document intake and
V- no response output.
M- flexion
4. Improve blood flow. 4. Fludrocortisone and
midodrine improve blood
Medical Hx: pressure and tissue
-Diabetes Insipidus perfusion.
ECG: Fludrocortisone increases
Possible Left atrial
enlargement. blood volume to increase
Incomplete Left bundle tissue perfusion, while
branch block; nonspecific midodrine raises the
ST and T wave blood pressure with
abnormality chronic orthostatic
hypotension.
ECHO: 5. Promote salt intake.
Ejection Fraction: 60% 5. Promote salt (sodium)
in the patient’s diet,
Holter: which can significantly
Infrequent isolated increase blood pressure
premature ventricular
and tissue perfusion.
contractions.
Sodium intake can be
beneficial for those with
LABS:
low blood pressure.
Albumin-low
-Start with Intravenous
Potassium- low
fluids to resuscitate
NT-ProBNP-high
hypovolemic shock.
Urea BUN- high
RBC-low
Hgb-low
WBC-high

ABG:
pH-high
PCO2-normal
PO2-normal
HCO3-high
(ACUTE METABOLIC
ALKALOSIS WITH
SECONDARY
RESPIRATORY
ACIDOSIS)
 ASSESSMENT NURSING EXPECTED IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS OUTCOME
SUBJECTIVE DATA: Risk for shock related to At the end of the shift, the 1.Assess the patient’s risk 1. Risk factors that can Partially met.
(Patient can’t decreased blood pressure, patient will be able to factors. lead to hypotension and At the end of the shift, the
communicate verbally: decreased blood volume, demonstrate - vomiting shock patient was able to
tracheostomized) decreased oxygen in the hemodynamic balance as -diarrhea demonstrate
blood and decreased evidenced by vital signs -diabetes insipidus hemodynamic balance as
oxygen in the tissue. within normal limits. -sepsis evidenced by vital signs
within normal limits.

OBJECTIVE DATA: 2. Monitor the patient’s 2. Severe hypotension is

T-35.9 C blood pressure. considered a hallmark
PR- 96bpm sign of shock. Note the
RR-30bpm presence of the following:
BP-93/47mmHg (post
bolus infusion from -Low blood pressure
ward) (hypotension)
02 sat- 96% (2lpm 02
supplement via
-Narrowing range
thermovent)
between systolic and
GCS- 9/10
diastolic BP (narrow
(+) feeble pulses
pulse pressure)

E-spontaneous
V- no response 3. Review laboratory and 3. Assess for the presence
M- flexion diagnostic studies results. of bleeding through
coagulation results and
Medical Hx: diagnostic scans to
-Diabetes Insipidus determine the cause of
ECG: shock
Possible Left atrial
enlargement. 4. Positioning the patient
Incomplete Left bundle 4. Place in Trendelenburg with their head lower
branch block; nonspecific position. than their feet can raise
ST and T wave blood pressure and aid in
abnormality perfusion to the brain and
 vital organs.
ECHO:
Ejection Fraction: 60% 5. Vasopressors such as
5.Administer
vasopressors. epinephrine or
Holter: vasopressin constrict
Infrequent isolated blood vessels to raise
premature ventricular blood pressure.
contractions.
6. Collaborate with the 6. Collaborate with the
LABS:
healthcare team. healthcare team for
Albumin-low
Potassium- low immediate management
NT-ProBNP-high of bleeding causing
Urea BUN- high hypotension and shock.
RBC-low Managing shock is an
Hgb-low emergency that requires a
WBC-high team to administer fluids,
blood products,
ABG: medications, and
pH-high oxygenation.
PCO2-normal
PO2-normal
HCO3-high
(ACUTE METABOLIC
ALKALOSIS WITH
SECONDARY
RESPIRATORY
ACIDOSIS)
 ASSESSMENT NURSING EXPECTED IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS OUTCOME
SUBJECTIVE DATA: Impaired gas exchange At the end of the shift the 1. Determine respiratory 1. Severe hypotension can Partially met.
(Patient can’t related to low patient will demonstrate status lower the body’s oxygen At the end of the shift the
communicate verbally: hemoglobin and ABGs within normal levels, compromising the patient partially
tracheostomized) hypovolemia as limits and will maintain gas exchange and demonstrated ABGs
evidenced by hypoxemia, oxygen saturation and production of oxygenated within normal limits and
tachycardia, tachypnea breathing pattern within blood to the brain and will maintain oxygen
and alteration of level of normal limits. heart. saturation and breathing
consciousness. pattern within normal
limits.

OBJECTIVE DATA: 2. Note any change in the 2. Change in mentation is

T-35.9 C level of consciousness. among the early
PR- 96bpm symptoms of inadequate
RR-30bpm gas exchange. Late signs
BP-93/47mmHg (post of impaired gas exchange
bolus infusion from include lethargy and
ward) somnolence.
02 sat- 96% (2lpm 02
supplement via 3. Assess for changes in
thermovent) 3. Record the changes in oxygen saturation, heart
GCS- 9/10 vital signs. rate, blood pressure,
(+) feeble pulses respiratory rate, and
cardiac rhythm.
E-spontaneous Hypoxemia can lead to
V- no response alterations in blood
M- flexion pressure, heart rate, and
arrhythmias.
Medical Hx:
-Diabetes Insipidus 4. Review hemoglobin 4. Inadequate alveolar gas
ECG: results. exchange occurs due to a
Possible Left atrial lack of blood supply and
enlargement. insufficient blood
Incomplete Left bundle pressure, which is evident
branch block; nonspecific through a decreased
ST and T wave hemoglobin level.
 abnormality
ECHO: 5. The body is at risk of
Ejection Fraction: 60% not obtaining enough
5. Perform continuous
telemetry and spo2 oxygen to perform its
Holter: function if the blood
monitoring.
Infrequent isolated pressure falls
premature ventricular dangerously low.
contractions. Reduced oxygen levels
can affect the gas
LABS: exchange in the heart and
Albumin-low lungs.
Potassium- low
NT-ProBNP-high 6. Prevent this by
Urea BUN- high ensuring adequate
6. Prevent hypotensive
RBC-low volume expansion
shock.
Hgb-low through IV fluids, blood
WBC-high products, and
medications.
ABG:
pH-high
PCO2-normal
PO2-normal
HCO3-high
(ACUTE METABOLIC
ALKALOSIS WITH
SECONDARY
RESPIRATORY
ACIDOSIS)

References
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