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    Karen Elizabeth B. Valdez Rle 2 Cues and Clues Nursing Diagnosis Analysis Goal and Objectives Implementation Rationale Evaluation

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    Karen Valdez
    The patient presented with signs and symptoms of shock including low blood pressure, rapid heart rate and respiratory rate, loss of consciousness, and abnormal lab values. Analysis indicated decreased cardiac contractility and output leading to decreased tissue perfusion. The goals were to restore adequate perfusion as evidenced by stable vital signs and organ function. Interventions included monitoring, supplemental oxygen, morphine to reduce pain and workload on the heart, and vasoactive medications like dopamine and dobutamine to increase cardiac output.

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    Karen Elizabeth B. Valdez Rle 2 Cues and Clues Nursing Diagnosis Analysis Goal and Objectives Implementation Rationale Evaluation

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    Karen Valdez
    582 views2 pages
    The patient presented with signs and symptoms of shock including low blood pressure, rapid heart rate and respiratory rate, loss of consciousness, and abnormal lab values. Analysis indicated decreased cardiac contractility and output leading to decreased tissue perfusion. The goals were to restore adequate perfusion as evidenced by stable vital signs and organ function. Interventions included monitoring, supplemental oxygen, morphine to reduce pain and workload on the heart, and vasoactive medications like dopamine and dobutamine to increase cardiac output.

    Original Description:

    NCP

    Original Title

    Risk for Shock

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    The patient presented with signs and symptoms of shock including low blood pressure, rapid heart rate and respiratory rate, loss of consciousness, and abnormal lab values. Analysis indicated decreased cardiac contractility and output leading to decreased tissue perfusion. The goals were to restore adequate perfusion as evidenced by stable vital signs and organ function. Interventions included monitoring, supplemental oxygen, morphine to reduce pain and workload on the heart, and vasoactive medications like dopamine and dobutamine to increase cardiac output.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    582 views2 pages

    Karen Elizabeth B. Valdez Rle 2 Cues and Clues Nursing Diagnosis Analysis Goal and Objectives Implementation Rationale Evaluation

    Uploaded by

    Karen Valdez
    The patient presented with signs and symptoms of shock including low blood pressure, rapid heart rate and respiratory rate, loss of consciousness, and abnormal lab values. Analysis indicated decreased cardiac contractility and output leading to decreased tissue perfusion. The goals were to restore adequate perfusion as evidenced by stable vital signs and organ function. Interventions included monitoring, supplemental oxygen, morphine to reduce pain and workload on the heart, and vasoactive medications like dopamine and dobutamine to increase cardiac output.

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    Karen Elizabeth B.

    Valdez
    RLE 2
    CUES AND
    NURSING
    CLUES
    DIAGNOSIS
    Vital Signs:
    Risk for shock
    BP = 80/60
    related to
    CR = 110/min
    hypoperfusion
    RR = 16/min
    of major
    organs
    Loss of
    consciousness
    ABG:
    pH = 7.30
    pCO2 = 70
    pO2 = 55
    HCO3 = 25

    ANALYSIS
    Decreased
    cardiac
    contractility
    Decreased
    stroke volume
    and cardiac
    output
    Decreased
    systemic tissue
    perfusion
    shock

    O2 sat = 80%
    ECG showed ST
    segment changes
    and PVC

    GOAL AND
    OBJECTIVES
    After 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.

    IMPLEMENTATION
    1. Monitor vital
    signs
    2. Monitor heart rate
    and rhythm. Note
    dysrhythmia

    3. Investigate
    changes in
    sensorium
    mental cloudiness,
    agitation,
    restlessness,
    personality
    changes, delirium,
    stupor, and coma.
    4. Assess skin for
    changes in color,
    temperature, and
    moisture
    5. Record hourly
    urinary output and
    specific gravity.
    6. Administer
    supplemental
    oxygen
    7. Administer
    morphine

    RATIONALE
    1. To assess
    changes
    associated with
    shock states
    2. To limit
    hypoxia, acidbase and
    electrolyte
    imbalance,
    and/or lowflow perfusion
    state.
    3. Changes in
    mentation
    reflect
    alterations in
    cerebral
    perfusion,
    hypoxemia,
    and/or acidosis
    4. To assess
    perfusion
    5. To assess renal
    perfusion
    6. To achieve
    oxygen
    saturation
    exceeding 90%
    7. To reduce chest
    pain and to
    reduce the
    workload of the

    EVALUATION

    8. Administer
    dopamine
    9. Administer
    dobutamine

    10. Administer IV
    nitroglycerin
    11. Administer other
    vasoactive
    medications

    heart because it
    dilates blood
    vessels
    8. To increase
    cardiac output
    9. To increase
    strength of
    myocardial
    activity and
    improve
    cardiac output
    10. To minimize
    cardiac
    workload
    11. To stimulate
    receptors of
    sympathetic
    nervous system
    to restore
    cardiac output

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