Question

In: Nursing

After the nurse re-assess his vital signs, his pulse is 140 and irregular. His respirations are...

After the nurse re-assess his vital signs, his pulse is 140 and irregular. His respirations are 32/min and his oxygen saturation is 85% on 3 liters of oxygen. His blood pressure is 132/45.

What are the priority nursing actions you would anticipate implementing when caring for Mr. Jones and why?

Solutions

Expert Solution

Answer-

Sl no Priority nursing actions Rational
1 Auscultate apical pulse, assess heart rate, rhythm. It provides base line data.
2 Monitor urine output Kidney respond to reduced cardiac output by retaining water and sodium.
3 Assess mental status and level of consciousness. The accumulation of waste products in bloodstream impairs oxygen transport and intake by cerebral tissues, which may manifest itself as confusion, lethargy, and altered consciousness.
4 Monitors oxygen saturation and ABGs. Provides information regarding the heart's ability to perfuse distal tissues with oxygenated blood.
5 Give oxygen as indicated by patient symptoms, oxygen saturation and ABGs. Make more oxygen available for gas exchange , assisting to alleviate signs of hypoxia and subsequent activity intolerance.
6 Implement strategies to treat fluild and eectrolytes imbalances. Decreases the risk for the development of cardiac output due to imbalances.
7 Encourage periods of rest and assist with all activities. Reduces cardiac workload and minimizes myocardial oxygen consumption.
8 Assist the patient in assuming a high Fowler's position . Allows for better chest expansion, thereby improving pulmonary capacity.
9 Reposition patient every 2 hours. To prevent occurrence of bed sores.
10 Administer mediaction as indiacted. like- furosemide. Furosemide decrease the blood pressure.
11 Administer supplemental oxygen as indicated. Increases avaliable oxygen for myocardial uptake to combat effects to hypoxia.

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