Nurse's Pocket Guide

• Refer to NDs ineffective Tissue Perfusion; risk for Autonomic
Dysreflexia.
NURSING PRIORITY NO.4.To promote venous return:
POSTACUTE/CHRONIC PHASE
• Provide for adequate rest, positioning client for maximum
comfort.
• Administer analgesics, as appropriate, to promote comfort/rest.
• Encourage relaxation techniques to reduce anxiety.
• Elevate legs when in sitting position; apply abdominal binder,
if indicated, to enhance venous return; use tilt table, as
needed, to prevent orthostatic hypotension.
• Give skin care, provide sheepskin or air/water/gel/foam mattress,
and assist with frequent position changes to avoid the
development of pressure sores.
• Elevate edematous extremities and avoid restrictive clothing.
When support hose are used, be sure they are individually fitted
and appropriately applied.
• Increase activity levels as permitted by individual condition/physiologic
response.
NURSING PRIORITY NO. 5.To maintain adequate nutrition and
fluid balance:
• Provide for diet restrictions (e.g., low-sodium, bland, soft,
low-calorie/residue/fat diet, with frequent small feedings), as
indicated.
• Note reports of anorexia/nausea and withhold oral intake, as
indicated.
• Provide fluids/electrolytes, as indicated, to minimize dehydration
and dysrhythmias.
• Monitor intake/output and calculate 24-hour fluid balance.
NURSING PRIORITY NO. 6. To promote wellness (Teaching/
Discharge Considerations):
• Note individual risk factors present (e.g., smoking, stress,
obesity) and specify interventions for reduction of identified
factors.
• Review specifics of drug regimen, diet, exercise/activity plan.
Emphasize necessity for long-term medical management of
cardiac conditons.
• Discuss significant signs/symptoms that require prompt
reporting to healthcare provider (e.g., muscle cramps,
headaches, dizziness, skin rashes) that may be signs of drug
toxicity and/or mineral loss, especially potassium.
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
Diagnostic Studies Pediatric/Geriatric/Lifespan Medications 149
decreased CARDIAC OUTPUT