Assessment
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Nursing DX/Clinical Problem
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Client Goals/Desired Outcomes/Objectives
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Nursing Interventions/Actions/Orders
and Rationale
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Subjective:
Daughter reported patient exhibited “mood swings” and
periods of “confusion.” Client expressed
she didn’t 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
Decreased urine output (0 ml/10 hours)
Elevated potassium level of 5.3
Elevated BUN (41)
Elevated Creatinine (1.73)
Post-CVA
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Problem
Ineffective tissue perfusion (cardiac, renal,
cerebral)
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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.
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-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.
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R/T
Decreased hemoglobin concentration in blood, exchange problems, impaired transport
of oxygen and interruption of blood flow secondary to subarachnoid hemorrhage
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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 dyspnea, syncope or
chest pain, and increased urine output by [date] at 16:00.
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-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 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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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).
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