(^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.
- No smoking—smoking contributes to cardiovascular disease, raising blood
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
12