Medical-surgical Nursing Demystified

(^38) Medical-Surgical Nursing Demystified
NURSING DIAGNOSES

• Imbalanced nutrition: more than the body requires.


• Knowledge deficit


• Excess fluid volume

NURSING INTERVENTION

• Monitor blood pressure with multiple readings—lying, sitting, and standing,
  bilateral both arms.


• Record fluid intake and output.
  Reduce stress by providing a quiet environment.


• Explain to the patient:
  
  
  • No smoking—smoking contributes to cardiovascular disease, raising blood
    pressure.
  
  
  • Change to a low-sodium and low-cholesterol diet—salt adds to elevated
    blood pressure in some patients by contributing to fluid retention; lower
    cholesterol intake lowers risk for associated hyperlipidemia.
  
  
  • Reduce alcohol intake—reduces risk for end organ damage from alcohol
    intake.
  
  
  • Reduce weight—decreased risk for obesity, better BP control with better
    weight control.
  
  
  • Exercise.
  
  
  • Call physician when BP is elevated.
  
  
  • Side effects of medications.
  
  
  
  

Hypovolemic Shock

WHAT WENT WRONG?

Rapid fluid loss causes inadequate circulation resulting in inadequate perfusion

of organs. Hypovolemic shock can be caused by external hemorrhage, fluids

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