NURSING MANAGEMENT (SOPIE)

DATE: 09/01/09

S> O

O>conscious

   >appears weak

   >(+)dyspnea

   >looks pale

   >irritable at times

   >with lab results of: Serum K= 1.75 mmol/min

   >with VS as follows: BP- 160/100; T- 35.9;   P- 87; R-15

A> Activity intolerance related to generalized muscle weakness secondary to decreased levels of potassium and sodium in the blood

P> After 8 hours of nursing interventions, patient will be able to deal with contributing factors of intolerances and manage activities within individual limits

I> Established rapport

 >Assessed general conditions

 >Monitored VS

 >Reduced intensity level or discontinued activities that cause undesired physiological changes

 >Provided supplemental O2

 >Planned care to carefully balance rest periods with activities

 >Provided positive atmosphere, while acknowledging difficulty of the situation for the client

 >Encouraged expression of feelings

 >Assisted with activities and provide use of assistive devices

 >Provided comfort measures

 >Assisted client in learning and demonstrating appropriate and safety measures

 >Administered medicines as ordered

E> Goal met, patient was able to deal with contributing factors of intolerances and managed activities within individual limits.

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NURSING MANAGEMENT (NCP)

CUES	NURSING DIAGNOSIS	SCIENTIFIC EXPLANATION	PLANNING	INTERVENTIONS	RATIONALE	EVALUATION
S> O O>conscious    >appears    weak    >irritable    and restless    at times    >(+) seizure    >with lab    results as      follows: Serum Na-101.2 mmol/l Serum K- 1.75 mmol/l    > with VS as    follows:    BP- 160/100    T- 35.9    P- 87    R-15	Risk for falls related to muscle weakness and episodes of seizures secondary to low levels of potassium in the blood	Because potassium and sodium are needed for normal nerve conduction and muscle function, low plasma potassium and sodium levels can often lead to weakness and can lead to falls or seizures Hypertension can cause deprivation of body cells of O2 secondary to decrease blood flow resulted from vasoconstriction. This can in turn causes weakness of the muscles and dizziness	After 8 hours of nurse-patient interaction, patient will be able to reduce risks of falls as evidenced by an absence of falls, bruises and seizures	1.        Establish rapport 2.        Assess general conditions 3.        Monitor VS 4.        Assist in treatments and provide information regarding patient’s present condition 5.        Discuss consequences of previously determined risk factors 6.        Discuss side effects of anti-hypertensive drugs 7.        Stress importance of monitoring conditions that may contribute to occurrence of falls 8.        Employ seizure precautions 9.        Keep bed in a low position with padded side rails up 10.     Before the client walk, clear the path of obstacles and place non-slippery shoes on the client	1.        To gain trust 2.        For baseline data 3.        To determine alterations which may indicate a need for interventions 4.        To determine individual risks 5.        For follow up instructions and interventions 6.        This can contribute to weakness and balance 7.        To reduce risks 8.        To minimize 9.        risk for injury	Goal met, patient was able to reduced risks of falls as evidenced by an absence of falls, bruises, contusions and seizures

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NURSING MANAGEMENT (NCP)

CUES	NURSING DIAGNOSIS	SCIENTIFIC EXPLANATION	PLANNING	INTERVENTIONS	RATIONALE	EVALUATION
S> O O>conscious    >appears     weak   >(+)dyspnea   >looks pale   >irritable at   times   >with lab   results of: Serum K= 1.75 mmol/min   >with VS as   follows:    BP- 160/100    T- 35.9    P- 87    R-15	Activity intolerance related to generalized muscle weakness secondary to decreased levels of potassium and sodium in the blood	Potassium and sodium are needed for muscle function and a decreased in its level can cause weakness. Hypertension can cause deprivation of body cells of O2 secondary to decrease blood flow resulted from vasoconstriction. This can in turn causes weakness of the muscles and dizziness	After 8 hours of nursing interventions, patient will be able to deal with contributing factors of intolerances and manage activities within individual limits.	1.        Establish rapport 2.        Assess general conditions 3.        Monitor VS 4.        Reduce intensity level or discontinue activities that cause undesired physiological changes 5.        Provide supplemental O2 6.        Plan care to carefully balance rest periods with activities 7.        Provide positive atmosphere, while acknowledging difficulty of the situation for the client 8.        Encourage expression of feelings 9.        Assist with activities and provide use of assistive devices 10.     Provide comfort measures 11.     Assist client in learning and demonstrating appropriate and safety measures 12.     Administered medicines as ordered	1.        To gain trust 2.        For baseline data 3.        To determine alterations which may indicate a need for interventions 4.        To prevent overexertion 5.        To assist client with O2 need 6.        To reduce need for O2 7.        This helps client to minimize frustration and rechannel energy 8.        To gain pertinent data 9.        To protect client from injury 10.     To enhance ability to participate activities 11.     To prevent injuries 12.     For compliance to medication regimen	Goal met, patient was able to deal with contributing factors of intolerances and managed activities within individual limits.

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SIGNS AND SYMPTOMS WITH ETIOLOGY

Headache – because of increased in intracranial pressure caused by fluid shift

Seizures – increased ICP that exceeds seizure threshold

Irritability, dizziness, disorientation – caused by decrease Oxygen supply in the brain or decreased nerve conduction

Nausea and vomiting – resulted from decreased smooth muscle contraction

Muscle weakness – because of decreased muscle contraction secondary to low levels of potassium and sodium; caused also by decreased Oxygen supplies to muscle cells

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PATHOPHYSIOLOGY of Hypertension

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SYNTHESIS OF THE DISEASE

SYNTHESIS OF THE DISEASE (hypertension)

Factors that predisposed the client to having hypertension includes age in which 30-50 years old are at high risks, being a male is also a risk according to statistics. Smoking which has a vasoconstrictive effect secondary to nicotine content of cigarette played a significant role in the pathogenesis of Hypertension. Likewise, excess alcohol consumption may also increase client’s risks.

Nicotine caused vasoconstriction and consequently narrowing of the lumen of the blood vessels. These both increases the peripheral resistance which increases arterial blood pressure and decreased blood flow which deprived O2 to muscle cells causing muscle weakness and to brain cells which can cause disorientation and irritability.

SYNTHESIS OF THE DISEASE (electrolyte imbalance)

                           Factors that predisposed the client to having electrolyte imbalances include poor intake, GI losses (vomiting), excessive perspiration and chronic alcoholism. These factors caused decreased Sodium in extracellular spaces leading to osmotic shift of water. Osmosis can in turn result to increased intracellular edema. The most sensitive cells are the neurologic cells in the brain. Increased in the volume of these cells causes increased ICP which resulted to headache and seizure.

                           On the other hand, when there is decreased potassium in extracellular spaces due to the above factors, there will be a decreased nerve conduction and muscle contraction. This will lead to symptoms such as disorientation and muscle weakness respectively. Slowed smooth muscle contraction is also the reason for nausea and vomiting.

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ANATOMY AND PHYSIOLOGY

CARDIOVASCULAR SYSTEM – responsible for the transport of O2 and CO2, nutrients and waste products.

I. Anatomy of the Heart

Location:

N  Apex- left at 5^th intercostals space

N  Base-towards the shoulder at 2^nd rib

Coverings and walls

Pericardium- a double layer sac that encloses the heart

Three layers

[  Epicardium- outer layer

[  Myocardium- middle layer

[  Endocardium- inner layer

Heart Chambers

[  Atria- upper receiving chambers

[  Ventricles- lower pumping chambers

Heart Valves

AV Valves- between atria and ventricles

[  Bicuspid- left AV valve

[  Tricuspid- right AV valve

Semilunar Valves

[  Pulmonic- at the pulmonary trunk

[  Aortic- at the aorta

Cardiac Circulation

[  Coronary arteries- supplies blood to the heart

II. Physiology of the Heart

Conduction System of the Heart

Two types of controlling system

1. Autonomic Nervous System

[  Symphatetic stimulation- increases heart rate

[  Parasymphatetic stimulation– decreases heart rate

2. Nodal System

[  SA Node – atrial contraction

[  AV Node

[  AV Bundle

[  Bundle Branches

[  Purkinje Fibers

CARDIOVASCULAR SYTEM: THE BLOOD VESSELS

Arteries- carries blood away from the the heart

Veins-brings blood back to the heart

Tunics

[  Interna

[  Media

[  Externa

Physiology of Circulation

Arterial Pulse – alternating expansion and recoil of an artery that occurs with each beat of the ventricles

Blood Pressure – pressure the blood exerts against the inner walls of the blood vessels

[  Systolic Pressure- the pressure in the arteries at the peak of ventricular contraction

[  Diastolic Pressure- the pressure when the ventricles are relaxing

Peripheral Resistance- amount of friction encountered by a blood as it flows through the blood vessels

Factors affecting Blood Pressure

[  Neural factors

[  Renal factors

[  Temperature

[  Chemicals

[  Diet

Variations in Blood Pressure

Hypotension- low BP; systolic BP of below 100 mmHg

Hypertension- 140/90 or higher

FLUID AND ELECTROLYTE BALANCE

Fluid Compartments- main location of water within the body

Intracellular Fluid (ICF)- 2/3 of the body fluids, contained within the living cells

Extracellular Fluid (ECF) – 1/3 of the body fluids;all body fluids outside the cells; includes blood plasma, interstitial, CSF and serous fluids

*Very small changes in electrolyte balance, the solute concentration in various fluid compartments cause water to move from one compartment to another

Sodium- the major extracellular cation, important for water balance, conduction of nerve impulse and muscle contraction

Potassium- the major intracellular cation, necessary for the conduction of nerve impulse and muscle contraction

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