Risk for ineffective tissue perfusion

Peripheral Assist with position changes. Obese patients encounter poor circulation in adipose tissue, which can create increased hypoxia in tissue Rolstad, Hypotension may occur because of shock circulatory collapse.

Indicative of meningeal irritation, especially in hemorrhage disorders. Urinary Elimination Client Outcomes Demonstrates adequate tissue perfusion as evidenced by palpable peripheral pulses, warm and dry skin, adequate urinary output, and the absence of respiratory distress Verbalizes knowledge of treatment regimen, including appropriate exercise and medications and their actions and possible side effects Identifies changes in lifestyle that are needed to increase tissue perfusion NIC Interventions Nursing Interventions Classification Suggested NIC Labels Nursing Interventions and Rationales Cerebral perfusion 1.

Note skin color and feel temperature of the skin. Record urine specific gravity as necessary. Change positions slowly when getting client out of bed. In some clients there is a palpable, tender venous cord that can be felt in the popliteal fossa.

Fever may be a sign of damage to hypothalamus. Fever and shivering can further increase ICP.

Ineffective Tissue Perfusion

More broad damage to the cerebral cortex may be manifested by slow reaction to commands, lapsing into sleep when not aroused, disorientation, and stupor. Prevents straining during bowel movement and corresponding increase of ICP. Pupil size and equality is determined by balance between parasympathetic and sympathetic innervation.

Refer to podiatrist if client has a foot or nail abnormality. Diposting oleh nic noc di Take serial leg measurements of the thigh and leg circumferences. Stable BP is needed to keep sufficient tissue perfusion. Check mental status; perform a neurological examination. Thin, shiny, dry skin with hair loss; brittle nails; and gangrene or ulcerations on toes and anterior surfaces of feet are seen in clients with arterial insufficiency.

Control environmental temperature as necessary. Evaluation provides a baseline for future comparison. Gauges of organ perfusion or function.

Particular clusters of signs and symptoms occur with differing causes. Interventions Rationales Submit patient to diagnostic testing as indicated. The elderly commonly have postural hypotension resulting from age-related losses of cardiovascular reflexes Matteson, McConnell, Linton, Diminished or absent peripheral pulses indicate arterial insufficiency Harris, Brown-Etris, Troyer-Caudle, Dysrhythmias and murmurs may reflect cardiac disease, which may have precipitated CVA stroke after MI or from valve dysfunction.

If caused by a thrombus and the client receives treatment within 3 hours, a stroke can often be reversed. Changes in rate, especially bradycardia, can occur because of the brain damage. Prepare for surgeryas appropriate: Seizures may reflect increased ICP or cerebral injury, requiring further evaluation and intervention.

High levels of D-Dimer, a febrin degradation fragment, is found in deep vein thrombosis, pulmonary embolism, and disseminated intravascular coagulation Pagana, Pagana, Obesity is a risk factor for development of chronic venous disease Kunimoto et al, Aerobic exercise training can reverse age-related peripheral circulatory problems in otherwise healthy older men Beere et al, Elevation increases venous return and helps decrease edema.

Refer to a dietitian if appropriate. New onset of these neurological symptoms can signify a stroke. Cardiopulmonary Check respirations and absence of work of breathing. Brownish discoloration of skin indicates chronic venous insufficiency Bright, Georgi, ; Feldman, Here are 8+ cerebrovascular accident (stroke) nursing care plans: Ineffective Cerebral Tissue Perfusion; Impaired Physical Mobility; Impaired Verbal Communication; Disturbed Sensory Perception; Ineffective Coping; Self-Care Deficit; Risk for Impaired Swallowing; Activity Intolerance; Risk for Unilateral Neglect.

Ineffective Tissue Perfusion: Decrease in oxygen, resulting in failure to nourish tissues at capillary level. Blood is a connective tissue comprised of a liquid extracellular matrix termed as blood plasma which dissolves and suspends multiple cells and cell fragments. It carries oxygen from the. perfusion [per-fu´zhun] 1.

the act of pouring through or over; especially the passage of a fluid through the vessels of a specific organ. 2. a liquid poured through or over an organ or tissue. tissue perfusion the circulation of blood through the vascular bed of tissue. ineffective tissue perfusion (specify type) (renal, cerebral, cardiopulmonary.

NCP Ineffective Tissue Perfusion - Download as Word Doc .doc /.docx), PDF File .pdf), Text File .txt) or read online. Scribd is the world's largest social reading and publishing site. Search Search5/5(1).

Deceased Cardiac Output, Ineffective Tissue Perfusion: cerebral, Disturbed Sensory Perception, visual and Deficient Fluid Volume.

You also look at the complications of the disease for things the person could be at risk for and either teach the patient how to avoid those things or develop strategies to help the patient avoid experiencing them.

8+ Cerebrovascular Accident (Stroke) Nursing Care Plans

Jul 22,  · Ineffective Tissue perfusion (specify type): cerebral, renal, cardiopulmonary, GI, peripheral Decrease in oxygen resulting in failure to nourish tissues at the capillary level.

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Risk for ineffective tissue perfusion
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