In: Nursing
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?
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. |