Nursing Care Plan Risk for decreased cardiac tissue perfusion

By On Sunday, September 16th, 2012 Categories : Nanda, Nursing Careplans

hipertensi2 300x243 Nursing Care Plan Risk for decreased cardiac tissue perfusionNursing Care Plan Risk for decreased cardiac tissue perfusion Definitio:Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane is a professional judgment based on the application of clinical knowledge which determines potential or actual experiences and responses to health problems and life processes. The list of nanda nursing diagnosis can be applied to individuals, families or communities. Included with the list of nanda nursing diagnosis is an array of commonly applied interventions from which the caregiver can choose to implement to the given patient. Standardized nursing language is a body of terms used in the profession that is considered to be understood in common. The use of common terms promotes patient safety by allowing nurses to quickly and efficiently understand the aspects of a patient’s needs. The use of standardized terms allows nursing staff to avoid sifting through long narratives in order to determine a particular patient’s needs and planned course of care. Nursing Care Plan Risk for decreased cardiac tissue perfusion

Defining Characteristics

  • Abnormal pH and arterial
  • Headache upon awakening blood gases levels
  • Hypoxia and hypoxemia
  • Abnormal respiratory rate,
  • Increased or decreased carbon
  • rhythm, and depth dioxide levels
  • Confusion
  • Irritability/Restlessness
  • Cyanosis
  • Nasal flaring
  • Diaphoresis
  • Pale, dusky skin
  • Dyspnea
  • Tachycardia

Related Factors

  • Alveolar-capillary membrane changes
  • Ventilation–perfusion changes

Assessment Focus    

  • Activity/exercise
  • Neurocognition
  • Cardiac function
  • Respiratory function

Expected Outcomes The Patient Will

  • Carry out ADLs without weakness or fatigue.
  • Maintain normal Hb and HCT levels.
  • Express feelings of comfort in maintaining air exchange.
  • Cough effectively and expectorate sputum.
  • Be free from adventitious breath sounds.
  • Perform relaxation techniques every 4 hr.
  • Use correct bronchial hygiene.

Suggested Noc Outcomes

Gas Exchange: Ventilation; Respiratory Statue: Gas Exchange; Vital Signs

Interventions And Rationales

Determine: Monitor respiratory status; rate and depth of breaths;chest expansion; accessory muscle use; cough and amount and color of sputum; and auscultation of breath sounds every 4 hr to detect early signs of respiratory failure.Monitor vital signs, arterial blood gases, and Hb levels to detect changes in gas exchange.Report signs of fluid overload or dehydration immediately. This can lead to changes in acid-base balance and affect respiratory status.Perform: Elevate head 30 to facilitate lung expansion and prevent atalectasis. Assist with ADLs as needed to decrease tissue oxygen.149 Perform bronchial hygiene as ordered (e.g., coughing, percussing,postural drainage, and suctioning) to promote drainage and keep airways clear. Administer bronchodilators, antibiotics, and steroids,as ordered.Record intake and output every 8 hr to monitor fluid balance.Auscultate lungs every 4 hr and report abnormalities to detect decreased or adventitious breath sounds. Orient patient to the environment, that is, use of call bell, side rails, and bed positioning controls. Place side rails up and bed position down when the patient is in bed. Place personal items within the patient’s reach. Assist patient when he or she is getting out of bed in case of dizziness. These measures prevent risk of falling. Move patient slowly to avoid hypostatic hypotension. Post a notice where it can be seen that the patient is at risk for falling.Inform: Teach and demonstrate correct breathing and coughing tech-niques such as diaphragmatic or abdominal breathing and have patient return demonstration to ensure patient understands proper technique and promote effective coughing and deep breathing.Teach patient correct way of using inhalers. Remind patient about mouth care after each dose. Failure to clean the mouth after inhal-ing can cause candidiasis in the throat.Review all medications with patient and family and list side effects for each to ensure that the patient recognizes side effects and reports them to the physician.Encourage relaxation techniques to reduce oxygen demand.Attend: Encourage patient to express feelings. Attentive listening helps build a trusting relationship.Encourage family members to stay with the patient, especially during times of anxiety to promote relaxation which reduces oxygen demand.Manage: Request for a case manager to make a home visit to help prepare family for the patient’s return to a safe environment.Refer patient to community resources and offer written informa-tion that can be referred to when needed.

Suggested Nic Interventions

Acid–Base Management; Airway Management; Airway suctioning;Anxiety Reduction; Energy Management; Exercise Promotion; Fluid Management

Reference

Marklew, A. (2006, January–February). Body positioning and its effect on oxygenation—A literature review. Nursing in Critical Care, 11(1), 16–22.

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