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M.M - Coggle Diagram

- - - - Client-Focused outcome (Wayne, 2023)
        
        Patient will keep still and not move the legs due to bleeding risk. Patient will report backpain to the nurse because that could indicate an aortic aneurysm.
        
        Interventions (Wayne, 2023)
        
        Nurse will check the patients femoral artery every hour to ensure there is no bleeding coming from the site.
        
        Nurse will monitor patients vital signs such as heart rate and blood pressure and watch for signs of orthostatic hypotension.
        
        Nurse will monitor for skin necrosis changes in blue or purple mottling of feet that black with pressure. Nurse will also monitor dorsal pedal pulses every hour to ensure adequate blood flow.
        
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  - - - Client-Focused outcome (Matthews et al; 2023)
        
        Patient will exhibit warm dry skin and have absence of pulmonary crackles
        
        Interventions (Matthews et al; 2023)
        
        Nurse will assess the patients heart rate and rhythm to ensure adequate cardiac output.
        
        Nurse will assess for jugular vein pulsations.
        
        Nurse will note skin color, temperature, and moisture of the skin to look at venous or arterial circulation.
        
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  - - - Client-Focused outcome (Jolly et al; 2023)
        
        Patient will be free from complications of immobility, as evidenced by intact skin, absence of thrombophlebitis, normal bowel pattern and clear breath sounds.
        
        Interventions (Jolly et al; 2023)
        
        Nurse will provide a safe environment such as placing bed in lowest position and placing important items close by the patient.
        
        Nurse will explain to the patient the need to call for help, such as using the call light when needed.
        
        Nurse will offer and administer pain medications as appropriate if patient is sore from being bed written.
  - - - Client-Focused outcome (Wayne, 2023)
        
        Patient will verbalize understanding of the disease process and what the treatment regimen is.
        
        Interventions (Wayne, 2023)
        
        Nurse will assess the client's health literacy and any barriers to learning such as cultural norms and values, environmental influences and social interaction patterns.
        
        Nurse will assess the patients need for visual or hearing aids to ensure patient is able to receive the medical information given to them.
        
        Nurse will involve the client in writing specific outcomes for teaching and identifying what is most important to learn from the patients viewpoint and lifestyle
        
        2 more items...
  - - - Client-Focused Outcome (Cantu et al; 2023)
        
        Patient will maintain maximum tissue perfusion to vital organs as evidenced by warm and dry skin, strong peripheral pulses, vital signs within the client's normal range, balanced input and output, absence of chest pain, normal arterial blood gas values, and alert level of consciousness during hospital stay.
        
        Interventions (Cantu et al; 2023)
        
        Nurse will check for pallor, cyanosis and cool or clammy skin. Nurse will assess the quality of every pulse (especially the dorsal pulses)
        
        Nurse will assess for signs of decreased tissue perfusion by evaluating the blood pressure on the arterial line and on the blood pressure cuff and the reading on the balloon pump (IABP)
        
        Nurse will check the hemodynamic study such as looking at the parameters such as the heart rate, blood pressure, central venous pressure, and pulmonary vascular pressure.