Nursing Diagnoses and Interventions (telemetry unit) correctly answered

Nursing Diagnoses and Interventions (telemetry unit)Impaired gas exchange related to increased preload and aveolar-capillary membrane exchanges as evidenced by abnormal oxygen saturation, hypoxemia, dyspnea, tachypnea, tachycardia, restlessness and patient's statement, "I am so short of breath." - correct answer Respiratory Monitoring, Oxygen Therapy, Positioning Respiratory Therapy - correct answer monitor pulse ox, RR, rhythm, depth, and effort of respirations to evaluate change in respiratory status, auscultate breath sounds, not areas of decreased or absence ventilation and presence of of adventitious sounds to detect presence of pulmonary edema Oxygen Therapy - correct answer administer supplemental O2 or other noninvasive ventilator support, monitor O2 flow rate and placement of O2 delivery device to ensure adequate delivery, change O2 delivery device from mask to nasal prongs during meals as tolerated to sustain O2 levels during meals, monitor effectiveness of O2 therapy to identify hypoxemia and establish range of O2 saturation Positioning - correct answer position in semi-fowler's position to alleviate dyspnea and improve ventilation by decreasing venous return to teh heart and increasing thoracic capacity Cardiac Care - correct answer perform comprehensive assessment of peripheral circulation (pulses, refill, edema, color, temperature) to determine circulatory status, Note S/S of decreased cardiac output (chest pain, S3 and S4, JVD), Monitor fluid balance, Contiuously monitor cardiac rhythm to detect dysrhythmias, monitor for dyspnea, fatigue, tachypnea, and othropnea to identify involvement or respiratory system. Instruct patient and caregivers on activity restriction and progression to allay fears and anxiety. Establish a supportive relationship with patient and family to promote adherence to treatment, inform patient of purpose and benefits of prescribed activity and exercise. Decreased cardiac output related to altered contractility, altered preload and altered stroke volume as evidenced by decreased ejection fraction, increased CVP, decreased peripheral pulses, jugular venous distention, orthopnea, chest pain, S3 and S4 sounds, and oliguria. - correct answer Cardiac Care Excessive fluid volume related to increased venous pressure and decreased renal perfusion secondary to heart failure as evidenced by a rapid weight gain, edema, adventitious breath sounds, oliguria, and patient's statement, "My ankles are so swollen." - correct answer Hypervolemia Management Hypervolemia Management - correct answer Administer diuretics, as appropriate, to treat hypervolemia, Monitor therapeutic effect of diuretic (increased output, decreased CVP, decreased adventitious breath sounds), Monitor K+ levels after diuresis to detect electrolyte loss, Weigh patient daily and monitor trends, Monitor intake and output to assess fluid status, Monitor respiratory pattern for symptoms of respiratory difficulty to detect pulmonary edema, Monitor hemodynamic status (CVP, MAP, PAWP), Monitor changes in peripheral edema Activity intolerance related to imbalance between O2 supply and demand secondary to cardiac insufficiency and pulmonary congestion as evidenced by dyspnea, shortness of breath, weakness, increase in heart rate on exertion, and patient's statement, "I am too tired to get out of bed; I have no energy." - correct answer Energy management, Activity therapy Energy management - correct answer encourage alternate rest and activity periods to reduce cardiac workload and conserve energy, provide calming diversionary activities to promote relaxation to reduce O2 consumption and to relieve dyspnea and fatigue, monitor O2 response (pulse, cardiac rhythm and RR) to determine level of activity that can be preformed, Teach patient and caregiver techniques that minimize O2 consumption Activity Therapy - correct answer collaborate with occupational/physical therapists to plan and monitor activity or exercise program, determine patient's commitment to increasing frequency and/or range of activities or exercise to provide patient with obtainable goals