Purpose:
The client will maintain adequate cardiac output in accordance with the needs of the body, with the following criteria:
- Peripheral pulse can be felt normal.
- Vital sign within normal limits.
- Normal capillary refill
- Good mental status
- No dysrhythmias
Nursing Interventions :
1. Monitor your blood pressure at the position of lying, sitting and standing if possible. Note the magnitude of the pressure pulse.
2. Check for chest pain or angina patient complained.
3. Auscultation breath sounds. Note the presence of abnormal noise.
4. Observation of signs and symptoms of severe thirst, dry mucous membranes, pulse
weakness, decreased urine output, and hypotension.
5. Record input and output.
Rational:
1. Orthostatic hypotension or general can occur as a result of excessive peripheral vasodilatation and a decrease in circulating volume.
2. A sign of increased oxygen demand by the heart muscle or ischemia.
3. S1 and prominent murmur associated with cardiac output increased in hypermetabolic state.
4. Rapid dehydration can occur which will reduce the volume of circulation and decrease cardiac output.
5. Losing too much fluid can cause severe dehydration.
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NAMA ANDA
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2 comments:
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