CLINICAL CASE DECISION INSTRUCTIONS

Clinical case decision instructruction | Nursing homework help

The intent of Mrs. Muller’s management would be to stabilize her condition, treat her acute heart failure, and improve her cardiogenic shock. This plan would include oxygen administration to increase oxygenation and nitroglycerin injections to dilate the coronary arteries. It also includes diuretics and inotropes (or vasopressors) to lower fluid in her lungs. There are also signs that Mrs. Muller is in worsening shock and heart failure, including decreased urine output and altered mental state.

Shortness of breath, cyanosis and impaired gas exchange are all signs that indicate pulmonary congestion.

Plan of Care

• Administer oxygen via nasal cannula at 2L/min to improve oxygenation
• Use diuretics to improve your breathing and reduce the fluid accumulation in the lungs.
• Monitor your vital signs including blood pressure and oxygen saturation.
• Fluid balance can be assessed by monitoring intake and output.
• Keep an eye out for any signs of heart failure and/or shock.
• Weight fluids daily to determine the amount of fluid in your body.

Reference: Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2017). Brunner & Suddarth’s textbook of medical-surgical nursing. Wolters Kluwer.

C4. In response to John’s blood loss, his body will experience several physiological responses aimed at compensating for the loss of blood volume. His sympathetic nervous system is activated to release epinephrine (which increases heart rate, contractility and blood vessel constrictions) and norepinephrine. This will then increase his blood pressure and blood flow. The sympathetic nervous system will activate to increase blood pressure and maintain the blood supply to critical organs such as heart and brain. John’s kidneys will also release renin, which will activate the renin-angiotensin-aldosterone system to increase blood volume by retaining sodium and water in the body. John’s urine production will drop, and thirst may occur.

Nurse Diagnosis : Reduced tissue perfusion due to bleeding as indicated by the laceration in the radial arterial.

Plan of Care

• Administer fluids, such as normal saline or lactated Ringer’s solution, to restore blood volume
• Monitor vital indicators, such as blood pressure, heartbeat, and oxygenation
• Fluid balance can be assessed by monitoring intake and output.
• Check for signs of hypovolemic shock, such as altered state of mind, decreased urine production, and cold clammy limbs.
• Elevate affected arm in order to promote vein return and reduce swelling
• To stop bleeding, apply pressure at the site of the laceration.
• Prepare for possible surgery or a blood transfusion, depending on your blood loss.

References: Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology. Elsevier. Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M., & Kwong, J. (2017). Medical-surgical Nursing: Assessment and Management of Clinical Problems. Mosby.