What nursing interventions are

What nursing interventions are

What nursing interventions are appropriate for Mrs. J. at the time of her admission?

Mrs. J. is being admitted to the ICU due to acute decompensated heart failure. The subjective and objective data obtained is the following: Mrs. J is overweight based on her height and weight (5 feet 9 inches and weighs 210.5 pounds). For three days she has been experiencing a low grade fever (99.68), pharyngitis, and malaise. She denies pain but feels that she cannot breathe due to dyspnea. She claims that her heart is running away which indicates tachycardia (HR 118 and irregular). Her heart rate is working harder to compensate for the low blood pressure of 90/58. Her peripheral pulses are +1, demonstrating jugular distention, and ventricular rate of 132 with atrial fibrillation. She has crackles at auscultation, decreased breath sounds on right lower lobe, coughing frothy blood-tinged sputum, with and a very low oxygen saturation level of 82%. This patient is having left sided heart failure based on the subjective and objective data obtained.

Intervention: Place patient on continuous oxygen 2-4 LPM via n/c.

Rationale: To alleviate dyspnea symptoms and allow patient not to work as hard breathing

Intervention: Establish guidelines and goals of daily activity.

Rationale: Patient will most likely be more willing to cooperate if she is included in the goals being set.

Intervention: Assess patient’s mentation regularly.

Rationale: This is to determine if the patient is becoming more severe. Anxiety and confusion are late signs when a patient is having decreased cardiac output.

Intervention: Keep patient semi to high-fowlers position.

Rationale: This will help alleviate some of the shortness of breath.

Intervention: Asses heart rate and blood pressure frequently.

Rationale: Sinus tachycardia and increased arterial blood pressure are in the early stages and the blood pressure decreases as the condition worsens.

Intervention: Assess peripheral pulses frequently.

Rationale: weak pulses are indicators of low cardiac output.

Intervention: Assess skin color and temperature.

Rationale: Cold and clammy skin is an indicator of low cardiac output and desaturation.

Intervention: Assess fluid balance and weight gain.

Rationale: A compromised regulatory system can result in sodium and fluid retention.

Intervention: Continuous assessment of lung sounds.

Rationale: Crackles are indicative of fluid accumulation and secondary to left ventricular failure.

Intervention: Asses urine input and output.

Rationale: Decreased urine output is an indicator of lack of renal perfusion.

Intervention: Assess for chest pain.

Rationale: Indicates lack of oxygen supply. (Ackley & Ladwig, 2011).