About
Condition in which there is not enough nutrients and oxygen reaching organs and cells usually related to underlying trauma or cause.
Assess
( Early) confusion, tachypnea, combativeness; ( Late) hypotension, shallow respirations, pulmonary edema, dysrhythmias, tachycardia, loss of consciousness, renal failure, thrombi, jaundice
Complications
Multi-organ dysfunction syndrome, cardiac or respiratory arrest, death
Diagnosis
- Confusion related to underlying metabolic changes.
- Anxiety related to fear of death and sense of impending doom.
- Inadequate tissue perfusion related to decreased oxygenation and/or nutrition.
- Risk for injury related to altered mental state
Goals
- The client will have adequate tissue perfusion.
- The client will have vital signs maintained within normal ranges.
- The client will be free from injury and complication.
Interventions
- Monitor vital signs closely, arterial blood gases, pulse oximetry.
- Administer fluids and/or blood products.
- Administer oxygen and continuously monitor pulse oximetry.
- Administer sedating agents, anxiolytics as indicated to decrease metabolic demands and decrease anxiety.
- Prepare for intubation and mechanical ventilation if condition worsens.
- Provide a presence for patient and family.
- Reorient patient frequently, monitor risk for injury.
- Continuously monitor urine output and cardiac rhythm.
- Provide support for family members during end stages if condition progresses.
ليست هناك تعليقات:
إرسال تعليق