Nursing Management Concept Map

XI.

NURSING MANAGEMENT CONCEPT MAP Nsg. Dx: Decreased cardiac output r/t vascular resistance secondary to hyper ension Cues: increased BP, RR and decreased AR and PR. Treatment: Amplodipine 5mg, Losartan 50 mg Interventions: - Have pt. lie down or in a comfortable position -Monitored intake and output -Have a patient use a commode or urinal. -Provided a restful environment by minimizing controllable stressors and unnecessary disturbances.

Nsg. Dx: Imbalance nutrition: less than body

Nsg. Dx:

requirement r/t inadequate food intake as evidenced by lack of appetite.

Disturbed sleep pattern r/t fear of therapeutic regimen [blood transfusion]

Cues:

Cues: Dark-big eyebags; Weak and pale; Drowsy; verbalized was not able to sleep the entire night

Interventions: -Keep environment quiet for sleeping, eliminate noise. -Perform nursing procedures all at the same time if possible before patient to go to sleep. -Adjust lighting by providing curtains.

Lack of interest in foods; Weak and pale Pale conjunctiva; Consumed ¼ of served meals

Treatment: Heraclene 3 mg Interventions: - Position the pt in a comfortable position. -Provide relaxing environment while eating. -Allow patient to choose foods she likes. -Provide companionship or assist the pt while eating to encourage nutritional intake

C/C: Difficulty of Breathing Admitting Dx: Chronic Renal Failure 2o Hypertensive Nephrosceloris Nsg. Dx:

Nsg. Dx: Altered peripheral tissue perfusion r/t decrease circulating hemoglobin Cues:increased BP, RR and decreased AR and PR. HgB=46

Laboratories: Hematology Treatment: Blood transfusion Interventions: - Slow the pace of care. Allow the pt. extra time to carry out activities. -Provided peaceful environment -Encouraged to eat serve meals -Monitor post BT reactions.

Nsg. Dx: Impaired gas exchange r/t ventilationperfusion imbalance. Cues:increased BP, RR and decreased AR and PR. HgB=46

Laboratories:Hematology Interventions: - Position pt in Semi-fowler’s position -Encouraged increased fluid intake -Encouraged/Assisted the pt. to eat small meals frequently. -Provided and encourage peaceful environment to rest and sleep.

Impaired urinary elimination r/t urinary retention Cues: Urine volume/fluid output= 100 cc within 8 hours; + edema noted on both cheeks Verbalized difficulty in voiding Treatment: Furosemide, 60 mg and Rowatinex 2 caps

Interventions: Provide an environment that encourages toileting; and administer meds as ordered.