Assessment A. Decreased cardiac output STO related to hyper-metabolic state secondary to hyperthyroidism B. Ineffective cardiopulmonary a.

. tissue perfusion related to related to hyper-metabolic state and decrease cardiac output b. secondary to hyperthyroidism S data
Nanghihina sya at nahihilo

Objectives

After 5 hours of nursing interventions, the patient will: Have a decrease in blood pressure from 140/90 mmhg to 120/80 mmhg or lower Have a decrease in cardiac rate from 138 bpm to 90 bpm c. Have a decrease in respiratory rate from 44 cpm to 25 cpm.

kaya kame ngpachek-up sa SLU. Nung papunta na kme LTO dito (BGHMC) bigla na lang After 3 days of nursing syang hinimatay sa daan. interventions, the patient will demonstrates adequate cardiac Complaints of easy fatigability output and tissue perfusion as evidenced by blood pressure O data and cardiac rate within normal With vital signs taken as parameters for the client follows: BP: 140/90 mmhg CR: 138 bpm RR: 44 cpm Temp: 38C Appears weak and pale Generalized body weakness noted Tachycardia noted

Nursing Interventions Monitor vital signs every 2 hours Monitor central venous pressure, if available Provides more direct measure of circulating volume and cardiac function Auscultate heart sounds Prominent S1 and murmurs are associated with forceful cardiac output of hypermetabolic state; development of S3 may warn of impending cardiac failure Investigate reports of chest pain or angina Chest pains / discomfort generally indicate inadequate blood supply to the heart, which may compromise cardiac output. Auscultate breath sounds, noting adventitious sounds such as crackles Early sign of pulmonary congestion, reflecting developing cardiac failure Monitor intake and output Decreased cardiac output results in decreased perfusion of the kidneys, with a resulting decrease in urine output. Place patient in semi- to high-

Evaluation Objectives fully met if the patient will manifest a decrease in BP from 140/90 to 120/80, a decrease in cardiac rate from 138 bpm to 90 bpm and a decrease in respiratory rate from 44 cpm to 25 cpm
Objectives partially met if

the patient will manifest a slight decrease in blood pressure, cardiac rate and respiratory rate from its baseline data
Objectives

unmet if the patients blood pressure, cardiac rate and respiratory rate will remain unchanged

fowlers position To increase gravitational blood flow Provide adequate rest periods This reduces metabolic demands and oxygen consumption Administer high-flow oxygen via mask or ventilator, as indicated To increase oxygen available for cardiac function/tissue perfusion Administer anti-hypertensive drug as ordered To lower and control high blood pressure Explain necessary restrictions, including consumption of a sodium-restricted diet and guidelines on fluid intake. Encourage to do relaxation techniques such as DBE Encourage to verbalize needs and concerns

Reference: Nurses Pocket Guide by Marilyn Doenges Medical Surgical Nursing by Brunner and Suddhart

ASSESSMENT

OBJECTIVES

INTERVENTIONS

EVALUATION

Impaired thermoregulation related to STO hyper-metabolic rate secondary to After 5 hours of nursing hyperthyroidism interventions, the patient will be able to experience: a. A decrease of body temperature S from 38C t0 37.2C and below b. A decrease in respiratory rate Medyo mainit-init na siya as from 44 cpm to 25 cpm verbalized by significant other. c. Absence of flushed skin O LTO With vital signs of: BP 140/90 mmHg After 3 days of nursing T 38 C interventions, patients body CR 138 bpm temperature and respiratory rate RR 44 cpm will return and maintain at With flushed skin. normal range. Skin is warm to touch. With increased respiration

Monitor vital signs Monitor for signs of dehydration Apply tepid sponge bath To promote heat loss by evaporation and conduction Remove excess clothing or blankets To promote heat loss by radiation and conduction Administer replacement fluids To support circulating volume and to prevent dehydration Promote adequate nutritional food intake especially high calorie containing foods To meet increased metabolic demands Maintain bed rest To reduce metabolic demands Provide a well ventilated room temperature A well ventilated room promotes thermoregulation Administer antipyretics as ordered Used to reduce fever by its central action on hypothalamus Promote client safety by instructing SO to stay at bedside

Objectives fully met if the

patient will manifest a decrease in body temperature from 38C t0 37.2C and below, absence of flushed skin and a decrease in respiratory rate from 44 cpm to 25 cpm
Objectives partially met if

the patient will manifest a slight decrease in body temperature and respiratory rate from its baseline data obtained.
Objectives not met if the

patients body temperature, and respiratory rate werent able to return and to maintain at normal range and flushed skin will be noted

 Hyperthermia can lead to seizure and convulsion Reference: Nurses Pocket Guide by Marilyn Doenges