Patients objective / evaluation criteria;
- Maintain adequate cardiac output according to the needs of the body
characterized by:
- Stable vital signs,
- normal peripheral pulses,
- normal capillary refill,
- good mental status,
- no dysrhythmias
Nursing Intervention:
Independent
- Monitor vital signs. Note the magnitude of the pressure pulse.
- Check / meticulous possibility complained of chest pain patients.
- Assess pulse / heart rate while the patient sleeps.
- Auscultation of heart sounds, note the extra heart sounds, a gallop rhythm and a systolic murmur.
- ECG monitor, record or note rate or in cardiac rhythm and the presence of dysrhythmias
- Observation of signs and symptoms of severe thirst, dry mucous membranes, weak pulse, slow capillary refill, decreased urine output, and hypotension
- Note adnya history of asthma / bronkokontriksi, pregnancy, sinus bradycardia / heart block progress to heart failure
- Give fluids through IV as indicated
- Give medications as indicated:
- Monitor the results of lab tests: serum potassium, serum calcium, sputum culture
- Perform regular ECG monitoring
- Give oxygen as indicated
- Prepare for surgery
