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NCP 5 Ineffective Tissue Perfusion
bs nursing
Southwestern University PHINMA
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NURSING CARE PLAN
Identified Problem: Pitting edema 2+ noted on both legs, feet and ankles Nursing Diagnosis: Ineffective Peripheral Tissue Perfusion related to Diabetes Mellitus Type 2 and hypertension as evidence by lower leg edema CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION Subjective: Pt. complained lower extremity edema
Objective: VITAL SIGNS BP: 135/85 mmHg high fowler’s position; PR: 86 bpm radial; RR: 20 cpm; Temperature: 36°C; O2 saturation level of 95% on room air (right index finger).
Patient manifested the following: pitting edema 2+ noted on both legs, feet and ankles
Lab results: CMP o Sodium: 133 mEq/L o Potassium: 6. mEq/L o BUN: 85 mg/dL o Createnine: 2. mg/dL CBC: o RBC: 3. million/mm o Hgb: 8 g/dL o Hct: 27%
Short Term Objectives: After 8-10 hours of nursing intervention, pt will be able to: Demonstrate increased perfusion as evidenced by absence of edema Verbalize understanding of risk factors or condition, therapy regimens, side effects of medications, and when to contact healthcare provider
Long Term Objectives: After 72 hours of nursing intervention, pt will be able to: Demonstrate behaviors and lifestyle changes to improve circulation (e. engage in regular exercise, cessation of smoking and drinking alcohol)
Independent:
1. Assess for signs of decreased tissue
perfusion.
2. Review laboratory data (ABGs, BUN,
creatinine, electrolytes, international
normalized ratio, and prothrombin time
or partial thromboplastin time) if
anticoagulants are utilized for
treatment.
3. Use pulse oximetry to monitor oxygen
saturation and pulse rate.
4. Check Hgb levels
5. Check for pallor, cyanosis, mottling,
cool or clammy skin. Assess quality of
every pulse.
- Particular clusters of signs and symptoms occur with differing causes. Evaluation of Ineffective Tissue Perfusion defining characteristics provides a baseline for future comparison.
- Blood clotting studies are being used to conclude or make sure that clotting factors stay within therapeutic levels. Gauges of organ perfusion or function. Irregularities in coagulation may occur as an effect of therapeutic measures.
- Pulse oximetry is a useful tool to detect changes in oxygenation.
- Low levels reduce the uptake of oxygen at the alveolar-capillary membrane and oxygen delivery to the tissues.
- Nonexistence of peripheral pulses must be reported or managed immediately. Systemic vasoconstriction resulting from reduced cardiac output may be manifested by diminished
Short Term: After 8 hours of nursing intervention, pt: Displayed absence of pitting edema Verbalized understanding of risk factors or condition, therapy regimens, side effects of medications, and when to contact healthcare provider
Long Term: After 72 hours of nursing intervention, pt: Verbalized to stop drinking alcoholic beverages Verbalized to engage in exercise like walking every day.
Mindanao State University – Iligan Institute of
Technology
COLLEGE OF NURSING
Medical and Surgical Nursing
6. Performed continuous pulse oximetry.
7. Note urine output
8. Assist with position changes.
9. Promote active/passive ROM
exercises
10 patient properly in a semi-
Fowler’s to high-Fowler’s as tolerated.
11 patient about nutritional status
and the importance of paying special
attention to obesity, hyperlipidemia,
and malnutrition.
12. Encourage smoking cessation.
13. Provide knowledge on normal tissue
perfusion and possible causes of
impairment.
skin perfusion and loss of pulses. Therefore, assessment is required for constant comparisons 6. Reduce renal perfusion may take place due to vascular occlusion. 7. This ensures adequate perfusion of vital organs. 8. Gently repositioning patient from a supine to sitting/standing position can reduce the risk for orthostatic BP changes. Older patients are more susceptible to such drops of pressure with position changes. 9. Exercise prevents venous stasis and further circulatory compromise. 10 positioning promotes improved alveolar gas exchange. 11. Malnutrition contributes to anemia, which further compounds the lack of oxygenation to tissues. Obese patients encounter poor circulation in adipose tissue, which can create increased hypoxia in tissue. 12. Smoking tobacco is also associated with catecholamines release resulting in vasoconstriction and ineffective tissue perfusion. 13. Knowledge of causative factors provides a rationale
for treatments
Peripheral vasodilators
Collaborative:
1. Submit patient to diagnostic testing
as indicated.
optimize cardiac output and perfusion. These enhance arterial dilation and improve peripheral blood flow.
1. A variety of tests are
available depending on the cause of the impaired tissue perfusion. Angiograms, Doppler flow studies, segmental limb pressure measurement such as ankle-brachial index (ABI), and vascular stress testing are examples
of these tests.
NURSING CARE PLAN
Identified Problem: Elevated serum potassium level
Nursing Diagnosis: Electrolyte Imbalance: Hyperkalemia rel ated to impaired renal function
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective:
- Complaints of nausea and vomiting that has been going on for 8 hours prior to arrival and also presence of banding headache. -Patient claims occasional palpitations early in the morning while in bed. -Has generalized muscle weakness, as reported by the patient. -Patient stated that he gets easily short of breath when walking 20 feet distance.
Objective: -Glasgow Coma Scale: 13 -Awake but lethargic VS: T: 37’C, PR: 98bpm,
Short Term Objectives:
After 8 hours of nursing intervention: Patient will manifest relief from headache, lethargy, nausea, and vomiting. Patient’s vital signs will be stable and serum potassium level will be controlled in acceptable range.
Long Term Objectives:
After 3 days of nursing intervention: The patient’s ECG results will be normal and no signs of hyperkalemia. The patient will manifest no signs of generalized muscle weakness. Patient’s laboratory values such as BUN, creatinine,
Independent: 1. Place patient on a continuous cardiac monitoring.
Monitor and record the patient’s vital signs.
Monitor laboratory values and report significant changes to the physician.
Insert foley catheter as ordered and sctrictly monitor intake and output at regular intervals.
Teach patient and SO what foods and beverages to avoid especially those rich in potassium.
Dependent: Administer medications as prescribed by the physician: IV glucose with insulin and sodium bicarbonate, Calcium gluconate, Sodium Polystyrene Sulfonate (kayexelate) Furosemide Albuterol Amlodipine Ondansetron Hydralazine
Collaborative:
Refer to dietician regarding patient’s Renal Diet.
Potassium excess depresses myocardial conduction; can progress to cardiac fibrillation and arrest.
Provide baseline data to know patient’s progress.
To prevent further complications.
An inability to excrete potassium adequately may lead to dangerously high potassium levels. Report an output of less than 30 ml/hour.
To prevent further increase of potassium levels and complications.
Helps prevent dehydration from nausea and vomiting. Diuretics such as Furosemide are prescribed when dietary restriction of sodium alone is insufficient to reduce edema by inhibiting reabsorption of sodium and water by kidneys. Albuterol is for the treatment of shortness of breath. Amlodipine and Hydralazine acts as antihypertensive drugs, controlling patient’s blood pressure to stay within normal range and also helps for those who have heart conditions. Ondansetron is used to treat nausea and vomiting.
Short Term:
After 8 hours of nursing intervention: Patient manifest relief from headache, lethargy, nausea, and no longer had episodes of vomiting. Patient’s vital signs is stable and serum potassium level is controlled in acceptable range as reflected with the lab results.
Long Term:
After 3 days of nursing intervention: The patient’s ECG is normal with no signs of hyperkalemia as shown on ECG results. Patient no longer manifest signs of generalized muscle weakness.
NCP 5 Ineffective Tissue Perfusion
Course: bs nursing
University: Southwestern University PHINMA
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