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Nursing Care Plan for Tissue Perfusion

The patient presented with leg pain when walking, pale and dry skin, weakness, and difficulty walking. The nurse diagnosed ineffective tissue perfusion due to decreased hemoglobin from malaria. Goals were to increase perfusion within 3 hours and ensure understanding of treatment to maintain perfusion within 8 hours. Interventions included vital signs, leg measurements, exercises, elevation, compression stockings, medications, and mobility assistance. Evaluation found

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484 views2 pages

Nursing Care Plan for Tissue Perfusion

The patient presented with leg pain when walking, pale and dry skin, weakness, and difficulty walking. The nurse diagnosed ineffective tissue perfusion due to decreased hemoglobin from malaria. Goals were to increase perfusion within 3 hours and ensure understanding of treatment to maintain perfusion within 8 hours. Interventions included vital signs, leg measurements, exercises, elevation, compression stockings, medications, and mobility assistance. Evaluation found

Uploaded by

monico39
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

NURSING CARE PLAN

Assessment Subjective: sumasakit yung paa ko pagnaglalakad as verbalized by the client. Objective: Patient has altered skin characteristics (pale, dry) Patient appears to be weak The patient has difficulty of walking (claudication) Patient is lethargic

Diagnosis Ineffective tissue perfusion related to decrease hemoglobin concentration in the blood as manifested by claudicating

Inference Transfer of Plasmodium vivax from aedeas egypti Cell lysis of chenes in the liver Decrease clotting factors 1,2,3,5,6,7 Decrease in platelet formation Bleeding Decrease blood flow

Planning Short term goal: After 2-3 hours of nursing intervention patient will demonstrate an increase in perfusion. Long term goal: After 8 hours of nursing intervention patient will be able to verbalize understanding of therapy regimen and how help increase tissue perfusion

Intervention Independent: Monitor Vital signs Determine duration of problem/ frequency of occurrence Measure circumference of extremities, as indicated

Rationale

Evaluation After 3 hours of nursing intervention client has demonstrated increase in perfusion as manifested by skin returning to normal color After 8 hours of nursing intervention patient was able to verbalize understanding of therapy regimen and ways how to help increase in perfusion goals met

To have a baseline data To note degree of impairment/ organ involvement Useful in identifying edema in involved extremity Which may indicate thrombus formation To maximize tissue perfusion

Check for calf tenderness, swelling, and redness Perform assistive ROM exercise

Labs: Hemoglobin @ 130g/L

Decrease hemoglobin levels Decrease tissue perfusion

Elevate Head of the bed at night

To increase gravitational blood flow

Dependent: Apply antithromboemb olic hose badages to lower extremities before arising from bed Administer medications as per doctors order with caution (e.g., vasodilators, anticoagulants) To help prevent venous stasis

Drugs used to improve tissue perfusion also carry a risk of adverse responses

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