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Karen Elizabeth B. ValdezRLE 2CUES AND CLUESNURSING DIAGNOSISANALYSISGOAL AND OBJECTIVESIMPLEMENTATIONRATIONALEEVALUATION
Vital Signs:BP = 80/60CR = 110/minRR = 16/min
Loss of consciousness
ABG:pH = 7.30pCO2 = 70pO2 = 55HCO3 = 25
O2 sat = 80%
ECG showed ST segment changes and PVCRisk for shock related to hypoperfusion of major organsDecreased cardiac contractility
Decreased stroke volume and cardiac output
Decreased systemic tissue perfusion
shockAfter nursing interventions, patient will display adequate perfusion as evidenced by stable vital signs, palpable peripheral pulses, skin warm and dry, usual level of mentation, individually appropriate urinary output, and active bowel sounds.1. Monitor vital signs
2. Monitor heart rate and rhythm. Note dysrhythmia
3. Investigate changes in sensoriummental cloudiness, agitation, restlessness, personality changes, delirium, stupor, and coma.4. Assess skin for changes in color, temperature, and moisture5. Record hourly urinary output and specific gravity.6. Administer supplemental oxygen
7. Administer morphine
8. Administer dopamine9. Administer dobutamine
10. Administer IV nitroglycerin
11. Administer other vasoactive medications
1. To assess changes associated with shock states2. To limit hypoxia, acid-base and electrolyte imbalance, and/or low-flow perfusion state.
3. Changes in mentation reflect alterations in cerebral perfusion, hypoxemia, and/or acidosis
4. To assess perfusion
5. To assess renal perfusion6. To achieve oxygen saturation exceeding 90%7. To reduce chest pain and to reduce the workload of the heart because it dilates blood vessels8. To increase cardiac output9. To increase strength of myocardial activity and improve cardiac output10. To minimize cardiac workload11. To stimulate receptors of sympathetic nervous system to restore cardiac output