|
Nursing diagnosis
|
Decreased cardiac output (00029)
related to altered afterload, altered
contractility and altered stroke volume, as evidenced
by: clammy skin, crackles, decreased peripheral pulses,
decreased systemic vascular resistance, edema, increased pulmonary vascular
resistance, oliguria, prolonged capillary refill, skin color changes |
|
Nursing interventions
|
Shock management: cardiac (4254); Circulatory care: mechanical
assist device (4064) Hemodynamic regulation (4150) |
|
Nursing activities
|
Note signs and symptoms of decreased output
Auscultate lung sounds
for crackles or other adventitious sounds
Perform a comprehensive
appraisal of peripheral circulation (e.g., check peripheral pulses, edemas,
capillary refill, color, and extreme temperature)
Monitor sensory
and cognitive capacities
Evaluate pulmonary artery pressures,
systemic pressures, cardiac output, and systemic vascular resistance, as
indicated
Monitor the device regularly to ensure proper
functioning
Observe cannulas for kinks or disconnection
Determine activated clotting times every hour, as appropriate
Administer positive inotropic/contractility medications
Maintain
fluid balance by administering IV fluids or diuretics, as
appropriate
Evaluate side effects of negative inotropic medications
Use strict aseptic technique in changing dressings Monitor
electrolytes, BUN, and creatinine daily |
Monitor weight daily
Obtain chest X-ray daily
Monitor for
fever and leukocytosis
Monitor and document heart rate rhythm, and
pulses
Evaluate effects of fluid therapy
Provide emotional
support for the patient and family
Monitor coagulation profiles
every 6 hr, as appropriate
Administer anticoagulants or
antithrombolytics, as ordered
Observe for hemolysis as indicated by
blood in the urine, hemolyzed blood specimens, increase in daily serum
hemoglobin, frank bleeding, and hyperkalemia
Monitor intake and
output
Monitor urine output every hour
Monitor electrolyte
levels
Recognize presence of blood pressure alterations
Minimize/eliminate environmental stressors |
|
Nursing diagnosis
|
Risk for bleeding (00206)
evidenced by treatment-related side effects
(cardiac surgery, ECMO, hemodilution) |
|
Nursing interventions
|
Bleeding precautions (code 4010)
Bleeding reduction
(code 4020) |
|
Nursing activities
|
Monitor the patient closely for hemorrhage
Note
hemoglobin/hematocrit levels before and after blood loss, as indicated
Monitor coagulation studies, including prothrombin time (PT),
partial thromboplastin time (PTT), fibrinogen, fibrin degradation/split
products, and platelets counts, as appropriate
Monitor for signs and
symptoms of persistent bleeding (e.g.; check all secretions for frank or
occult blood)
Perform proper precautions in handling blood products
or bloody secretions
Avoid injections (IV, IM or SC), as
appropriate |
Maintain patent IV access
Administer blood products (e.g.,
platelets and fresh frozen plasma), as appropriate Monitor trends in blood
pressure and hemodynamic parameters, if available (e.g., central venous
pressure and pulmonary capillary/artery wedge pressure)
Monitor
determinants of tissue oxygen delivery (e.g., PaO2,
SaO2, and hemoglobin levels and cardiac output), if available
Monitor the amount and nature of blood loss
Refrain from
inserting objects into a bleeding orifice |
|
Nursing diagnosis
|
Impaired spontaneous ventilation
(00033) related to metabolic factors (increased
metabolic rate, metabolic acidosis) as evidenced by:
decreased pO2, decreased SaO2, and increased
pCO2
|
|
Nursing interventions
|
Respiratory monitoring (code 3350)
Mechanical
Ventilation management: invasive (code 3300) |
|
Nursing activities
|
Monitor rate, rhythm, depth, and effort of respirations
Note chest
movement, watching for symmetry, use of accessory muscles, and
supraclavicular and intercostal muscle retractions
Monitor chest
x-ray reports
Routinely monitor ventilator settings
Monitor
the effectiveness of MVon patient's physiological and psychological status
Monitor for adverse effects of mechanical ventilation: infection,
barotrauma, reduced cardiac output
Check all ventilator connections
regulary |
Monitor patient's respiratory secretions
Determine the need for
suctioning by auscultating for crackles and bronchi over major airways
Monitor for respiratory muscle fatigue
Ensure that
ventilator alarms are on
Monitor effects of ventilator changes on
oxygenation: ABG, SaO2, SvO2, end-tidal
CO2, Qsp/Qt, A-aDO2, patient's subjective response
Monitor for decrease in exhaled volume and increase in inspiratory
pressure
Provide routine oral care |
|
Nursing diagnosis
|
Risk for infection (00004)
evidenced by inadequate primary defenses (immature
immune system, broken skin/open surgical wound and altered peristalsis),
inadequate secondary defenses (decreased hemoglobin), increased
environmental exposure to pathogens, multiple invasive procedures |
|
Nursing interventions
|
Infection control (6540)
Infection protection
(6550) |
|
Nursing activities
|
Do the observance of universal precautions
Ensure appropriate
wound care technique
Monitor for systemic and localized signs and
symptoms of infection
Inspect condition of any surgical
incision/wound |
Ensure aseptic handling of all IV lines
Obtain cultures, as needed
Monitor absolute granulocyte count, WBC count, and differential
results |
