fibrillation, systolic murmur and fluid in his lungs AEB cool-pale extremities, coarse lung sounds, increased RR, variations in blood pressure readings and lab results. Goal: Pt will demonstrate adequate cardiac output AEB blood pressure, pulse rate and respiratory rate within normal parameters for client. Intervention: Monitored pt for signs of fluid overload. Assessed pts daily weight, I/Os, lung/heart/breath sounds, LOC and lab results. Educated family on the S/S of fluid overload, when to contact doctor, and discussed disease processes as well. Rationale: Increased weight, decreased output, crackles in lungs, irregular HR and moist or rapid RR could indicate pulmonary edema and respiratory distress. Intervention: Provided a restful environment by reducing stressors and unnecessary disturbances. Rationale: Rest periods decrease oxygen consumption. Intervention: Checked pts blood pressure and apical pulse before administering cardiac medications, then administered medications as prescribed. Also, educated family as to why pt needs to take his medications regularly. Rationale: These medications lower BP and HR, and improve his cardiac output, which can reduce the possibility of pulmonary edema. Intervention: Place pt with HOB elevated to position of comfort. Rationale: Elevating the head of the bed may decrease the work of breathing, and also decrease venous return and preload.
watery stools and vomiting AEB pts abnormal lab results for potassium, magnesium, calcium, and chloride serum level. Goal: Pt will maintain normal serum electrolyte levels by the time of his next lab result. Interventions: Administer electrolyte replacement therapy by IV. Rationales: Help restore potassium levels back to normal range. Interventions: Monitor pt for adverse effects of IV therapy. Rationales: Electrolyte imbalances can cause very serious complications in pts. Interventions: Monitor pts vital signs and lab results to assess how pt is tolerating IV infusions. Rationales: Pts BP, RR, HR, LOC, I/Os and serum lab results are indicators for adverse effects and abnormal electrolyte imbalances, which can be very detrimental to the pt, and can be fatal.
Pt Room #406
Nursing Dx #3: Chronic confusion r/t pts mental
history and current mental status AEB pts and familys statements in addition to my assessment and observation of pt. Goal: Pt. will remain calm and be free from harm, and will exhibit minimal agitation during my shift. Intervention: Identified myself during interactions with pt, and called pt by name during all contact as well. Rationale: Helped reduce pts confusion and anxiety r/t his hospitalization. Intervention: Approached client in a calm and caring manner. Rationale: Helped reduce stress, agitation and confusion, especially in dementia/Alzheimers pts. Intervention: Gave pt simple, one-step directions to follow, and engaged pt in communication. Rationale: Helped to reduce possibility of the pt becoming discouraged and agitated. Encouraged client interaction, and may help reduce stress/confusion r/t hospitalization.
Additional Nursing Dx:
Excess Fluid Volume</P></ITEM> Compromised Family Coping Knowledge Deficient[Family] Impaired Skin Integrity Risk for Fluid Deficit Risk for Injury</P></ITEM> Pain Ineffective Airway Clearance <ITEM><P>Fatigue Impaired <ITEM><P>Gas Exchange