NCP 5 Ineffective Tissue Perfusion PDF

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NCP ineffective tissue perfusion...

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Mindanao State University – Iligan Institute of Technology

COLLEGE OF NURSING Medical and Surgical Nursing 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 Short Term Objectives: Independent: Subjective: 1. Particular clusters of signs After 8-10 hours of nursing Pt. complained lower extremity and symptoms occur with intervention, pt will be edema 1. Assess for signs of decreased tissue differing causes. Evaluation able to: perfusion. of Ineffective Tissue Objective:  Demonstrate increased Perfusion defining VITAL SIGNS perfusion as evidenced characteristics provides a BP: 135/85 mmHg high fowler’s by absence of edema baseline for future position; PR: 86 bpm radial;  Verbalize understanding comparison. RR: 20 cpm; Temperature: of risk factors or 36.5°C; O2 saturation level of 2. Blood clotting studies are 2. Review laboratory data (ABGs, BUN, condition, therapy 95% on room air (right index being used to conclude or creatinine, electrolytes, international regimens, side effects of finger). make sure that clotting normalized ratio, and prothrombin time medications, and when to factors stay within Patient manifested the or partial thromboplastin time) if contact healthcare therapeutic levels. Gauges following: provider anticoagulants are utilized for of organ perfusion or  pitting edema 2+ noted on treatment. both legs, feet and ankles function. Irregularities in coagulation may occur as an effect of therapeutic Long Term Objectives: Lab results: After 72 hours of nursing measures.  CMP 3. Use pulse oximetry to monitor oxygen intervention, pt will be 3. Pulse oximetry is a useful o Sodium: 133 mEq/L able to: saturation and pulse rate. tool to detect changes in o Potassium: 6.5  Demonstrate oxygenation. mEq/L behaviors and lifestyle 4. Low levels reduce the 4. Check Hgb levels o BUN: 85 mg/dL changes to improve uptake of oxygen at the circulation (e.g. o Createnine: 2.8 alveolar-capillary engage in regular mg/dL membrane and oxygen exercise, cessation of  CBC: delivery to the tissues. smoking and drinking o RBC: 3.2 5. Nonexistence of peripheral 5. Check for pallor, cyanosis, mottling, alcohol) million/mm3 pulses must be reported or cool or clammy skin. Assess quality of o Hgb: 8.6 g/dL managed immediately. every pulse. o Hct: 27.4% Systemic vasoconstriction resulting from reduced cardiac output may be manifested by diminished

EVALUATION 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.

6. Performed continuous pulse oximetry. 7. Note urine output 8. Assist with position changes.

6.

7. 8.

9. Promote active/passive ROM exercises

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10. Position patient properly in a semiFowler’s to high-Fowler’s as tolerated.

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11. Educate patient about nutritional status and the importance of paying special attention to obesity, hyperlipidemia, and malnutrition.

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12. Encourage smoking cessation.

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13. Provide knowledge on normal tissue perfusion and possible causes of impairment.

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skin perfusion and loss of pulses. Therefore, assessment is required for constant comparisons Reduce renal perfusion may take place due to vascular occlusion. This ensures adequate perfusion of vital organs. 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. Exercise prevents venous stasis and further circulatory compromise. Upright positioning promotes improved alveolar gas exchange. 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. Smoking tobacco is also associated with catecholamines release resulting in vasoconstriction and ineffective tissue perfusion. Knowledge of causative factors provides a rationale

for treatments

14. Encourage change in lifestyle that could improve tissue perfusion (avoiding crossed legs at the knee when sitting, changing positions at frequent intervals, rising slowly from a supine/sitting to standing position, avoiding smoking, reducing risk factors for atherosclerosis [obesity, hypertension, dyslipidemia, inactivity]).

14. These measures

15. Teach patient to recognize the signs and symptoms that need to be reported to the nurse.

15. Early assessment

reduce venous compression/venous stasis and arterial vasoconstriction.

facilitates immediate treatment.

Dependent:

1. Check for optimal fluid balance. Administer IV fluids as ordered.

1. Sufficient fluid intake maintains adequate filling pressures and optimizes cardiac output needed for tissue perfusion. 2. These facilitate perfusion when interference to blood flow transpires or when perfusion has gone down to such a serious level leading to ischemic damage.

2. Consider the need for potential embolectomy, heparinization, vasodilator therapy, thrombolytic therapy, and fluid rescue. 3. Administer medications as prescribed to treat underlying problem. Note the response.

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Antihypertensives 

These reduce systemic vascular resistance and

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Peripheral vasodilators

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optimize cardiac output and perfusion. These enhance arterial dilation and improve peripheral blood flow.

Collaborative:

1. Submit patient to diagnostic testing as indicated.

NURSING CARE PLAN Identified Problem: Elevated serum potassium level Nursing Diagnosis: Electrolyte Imbalance: Hyperkalemia related to impaired renal function

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.

CUES 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.

OBJECTIVES 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:

Objective: -Glasgow Coma Scale: 13 -Awake but lethargic VS: T: 37.4’C, PR: 98bpm,

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,

INTERVENTIONS Independent: 1. Place patient on a continuous cardiac monitoring. 2. Monitor and record the patient’s vital signs.

RATIONALE 1. Potassium excess depresses myocardial conduction; can progress to cardiac fibrillation and arrest. 2. Provide baseline data to know patient’s progress. 3. To prevent further complications.

3. Monitor laboratory values and report significant changes to the physician. 4. Insert foley catheter as ordered and sctrictly monitor intake and output at regular intervals.

5. 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

4. An inability to excrete potassium adequately may lead to dangerously high potassium levels. Report an output of less than 30 ml/hour. 5. To prevent further increase of potassium levels and complications.

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Collaborative: Refer to dietician regarding patient’s Renal Diet.

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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.

EVALUATION 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.

To provide adequate nutrition to the patient....