Karen Elizabeth B. ValdezRLE 2CUES AND CLUESNURSING
DIAGNOSISANALYSISGOAL AND
OBJECTIVESIMPLEMENTATIONRATIONALEEVALUATION
Vital Signs:BP = 80/60CR = 110/minRR = 16/min
Loss of consciousness
ABG:pH = 7.30pCO2 = 70pO2 = 55HCO3 = 25
O2 sat = 80%
ECG showed ST segment changes and PVCRisk for shock related to
hypoperfusion of major organsDecreased cardiac contractility
Decreased stroke volume and cardiac output
Decreased systemic tissue perfusion
shockAfter 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.1. Monitor
vital signs
2. Monitor heart rate and rhythm. Note dysrhythmia
3. Investigate changes in sensoriummental cloudiness, agitation,
restlessness, personality changes, delirium, stupor, and coma.4.
Assess skin for changes in color, temperature, and moisture5.
Record hourly urinary output and specific gravity.6. Administer
supplemental oxygen
7. Administer morphine
8. Administer dopamine9. Administer dobutamine
10. Administer IV nitroglycerin
11. Administer other vasoactive medications
1. To assess changes associated with shock states2. To limit
hypoxia, acid-base and electrolyte imbalance, and/or low-flow
perfusion state.
3. Changes in mentation reflect alterations in cerebral
perfusion, hypoxemia, and/or acidosis
4. To assess perfusion
5. To assess renal perfusion6. To achieve oxygen saturation
exceeding 90%7. To reduce chest pain and to reduce the workload of
the heart because it dilates blood vessels8. To increase cardiac
output9. To increase strength of myocardial activity and improve
cardiac output10. To minimize cardiac workload11. To stimulate
receptors of sympathetic nervous system to restore cardiac
output
