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Atrial flutter accompanied by severe abdominal pain and dyspnea - Coggle…

- - - - Nursing Interventions:
        Monitor patient's BP, pulse rate, and rhythm often.
        Auscultate patient's heart sounds often (5 sites).
        Monitor patient's ECG.
        Frequently assess patient's respiratory rate, rhythm, breath sounds, and O2 saturation—monitor for the use of accessory muscles and dyspnea along with auscultating pt.'s lungs.
        Routinely assess for capillary refill in extremities and peripheral pulses.
        Assess for S/S of DVT, PE, stroke, and the patient's LOC.
        Routinely assess the patient's extremities for edema, skin turgor, color, temperature, and moisture.
        Assess for angina.
        Monitor I&O: urine output.
        Assess the patient's level of activity tolerance.
        Monitor labs: CBC, electrolytes, BNP.
        
        Evaluation: Patient demonstrated adequate cardiac output during my 12-hour shift on the unit, evidenced by BP, HR, and rhythm within normal ranges.
    - - Nursing Interventions:
        Monitor the patient's I&O, and encourage fluids unless the patient is on fluid restrictions.
        Monitor for peripheral edema and JVD-fluid retention.
        Assess vitals often: BP, HR, O2, RR, and LOC.
        Assess skin, hair, and nails for any abnormalities.
        Monitor labs for electrolyte imbalances, Hgb, Hct, and RBCs.
        Assess GI for decreased or absent peristalsis, nausea, vomiting, abdominal distention, and constipation.
        If ordered, Administer IV fluids as prescribed to maintain electrolyte/fluid balance.
        Assess patient's pain level: chest pain and overall.
        Administer standing order of oxygen if the patient becomes hypoxic and notify the physician.
        
        Evaluation: Patient maintained adequate tissue perfusion evidenced by warm and dry skin, present and strong peripheral pulses, vitals within normal range, balanced I&Os, and absence of edema during the first 12 hours on the unit.
  - - - Nursing Interventions:
        Frequently monitor and assess the patient's respiratory rate, rhythm, depth, and breathing effort. Use accessory muscles, nasal flaring, tripoding, or compensatory mechanisms?
        Position patient with head of the bed elevated, semi-Fowler's to allow increased lung expansion.
        Auscultate lungs for any areas of decreased breath sounds or the presence of any adventitious breath sounds.
        Monitor patient's LOC frequently.
        Monitor ABGs.
        Continually monitor patient's O2 saturation, apply standing order of oxygen if needed & contact physician.
        Assess the patient's activity level for restlessness, fatigue/lethargy, or weakness.
        Assess vital signs frequently, specifically BP & HR.
        Assess the patient's skin, oral mucosa, and lips for color and moisture.
        Provide reassurance and try to help reduce the patient's anxiety if applicable.
        Teach breathing exercises such as pursed-lip breathing, slow deep breathing, and use of an incentive spirometer.
        Monitor the effects of medication that could suppress the patient's respiratory drive.
        If the patient can, encourage ambulation and frequent position changes to promote lung expansion and secretion mobilization.
        
        Evaluation: Patient maintained adequate gas exchange during the first 12 hours on the unit, evidenced by unlabored respiration (RR), ABGs, HR, and O2 saturation, all within the safe and normal range.
    - - Nursing Interventions:
        Frequently monitor and assess pt.'s respiratory rate, rhythm, depth, the effort of breathing, and O2 saturation.
        Monitor for the use of accessory muscles, nasal flaring, tripoding, diaphragmatic muscle fatigue or weakness (paradoxical motion), or any compensatory mechanisms while breathing. Monitor for the use of accessory muscles, nasal flaring, tripoding, diaphragmatic muscle fatigue or weakness (paradoxical motion), or any compensatory mechanisms while breathing.
        Auscultate lungs for any areas of decreased breath sounds or the presence of any adventitious breath sounds.
        Assess patient for the presence of sputum: amount, color, consistency. If sputum is present, assess pt.'s ability to mobilize secretions.
        Patient teaching regarding the incentive spirometer, deep breathing,-highlighting slow inhalation, holding end inspiration for a few seconds, and passive exhalation, along with coughing to loosen secretions if present.
        Teach breathing exercises such as pursed-lip breathing, slow deep breathing, and use of an incentive spirometer. If present, teach the patient how to suction secretions.
        
        Evaluation: Patient remained free of signs of respiratory distress and verbalized an understanding of therapeutic interventions to optimize oxygenation within the first 6 hours on the unit.
  - - - Nursing Interventions:
        Frequently assess the patient's LOC (time, place, person, current event) and note any changes in the patient's orientation, consciousness, and responsiveness to stimuli.
        Frequently assess the patient's pupillary response to light (PERRLA), size of pupils, symmetry, eye-opening in response to stimuli, vision changes (depth perception, etc.)
        Frequently assess patient's speech (aphasia, dysphagia, dysarthria) and affect appropriate/inappropriate/flat, etc.)
        Assess patient's ability to swallow, presence of gag reflex
        Assess patient's respiratory function, RR, difficulty breathing (labored, dyspnea, use of accessory muscles, etc.)
        Frequently assess the patient's memory and judgment.
        Monitor vital signs continuously.
        Try to cluster care to allow adequate patient rest and quiet time.
        
        Evaluation: Patient maintained her current level of consciousness, cognition, and motor function during my 12-hour shift.
    - - Nursing Interventions:
        Frequently assess vital signs and the patient's pain level (0 out of 10).
        Monitor for signs and symptoms: sudden, persistent chest pain/palpitations, cough, dyspnea, low oxygen saturation, respiratory compensation mechanisms such as tripoding, irregular and increased heart rate,
        and light-headedness.
        Administer appropriate anticoagulant (Warfarin) or Heparin to prevent clot formation or thrombolytic therapy to break up/dissolve the current clot(s). Monitor PT, INR, and PTT.
        If needed, administer a standing order of oxygen or, as ordered to maintain an adequate oxygen saturation level.
        
        Evaluation: Patient remained free from forming an arterial thrombosis/thromboembolism during my 12-hour shift.