Assessment Rationales Assess for signs of decreased tissue perfusion. Cerebral Check rapid changes or continued shifts in mental status. Record urine specific gravity as necessary.
Pupil size and equality is determined by balance between parasympathetic and sympathetic innervation. Based on data from 16 studies, fatal pulmonary embolisms have been reported in one third of trauma clients Agency for Healthcare Research and Quality, Hypotension may occur because of shock circulatory collapse.
Check mental status; perform a neurological examination. Refer to podiatrist if client has a foot or nail abnormality. Patient identifies factors that improve circulation. Assess for pain in extremities, noting severity, quality, timing, and exacerbating and alleviating factors. Fever and shivering can further increase ICP.
Thin, shiny, dry skin with hair loss; brittle nails; and gangrene or ulcerations on toes and anterior surfaces of feet are seen in patients with arterial insufficiency. Control environmental temperature as necessary. Exercise prevents venous stasis and further circulatory compromise.
Prepare for surgeryas appropriate: Nevertheless, abrupt or continuous dyspnea may signify thromboembolic pulmonary complications.
Nonexistence of peripheral pulses must be reported or managed immediately. More broad damage to the cerebral cortex may be manifested by slow reaction to commands, lapsing into sleep when not aroused, disorientation, and stupor. Fever may be a sign of damage to hypothalamus.
If client is mostly immobile, consult with physician regarding use of calf-high pneumatic compression device for prevention of DVT.
Assesses trends in level of consciousness LOC and potential for increased ICP and is useful in determining location, extent, and progression of damage. Recognize that if elderly develop a pulmonary embolus, the symptoms often mimic those of heart failure or pneumonia Hyers, Systemic vasoconstriction resulting from reduced cardiac output may be manifested by diminished skin perfusion and loss of pulses.
Cluster nursing interventions and provide rest periods between care activities. In addition, it is directly related to cardiac output. Gauges of organ perfusion or function. If new onset of loss of pulses with bluish, purple, or black areas and extreme pain, notify physician immediately.
Thrombosis with clot formation is usually first detected as swelling of the involved leg and then as pain. Check for optimal fluid balance.
Monitor laboratory studies as indicated: Administer IV fluids as ordered. Administer medications as prescribed to treat underlying problem.
Evaluate motor reaction to simple commands, noting purposeful and nonpurposeful movement. Obesity is a risk factor for development of chronic venous disease Kunimoto et al, In clients with arterial insufficiency the pain increases with elevation of the legs and exercise Black, Evaluate pupils, noting size, shape, equality, light reactivity.
Note presence of edema in extremities and rate it on a four-point scale.
Pay meticulous attention to foot care. Changes in cognition and speech content are an indicator of location and degree of cerebral involvement and may indicate deterioration or increased ICP.
All of these risk factors for atherosclerosis can be modified Bright, Georgi, If minimum damage has taken place in the cerebral cortex, patient may be stimulated by verbal stimuli but may show drowsy or uncooperative. Cellulitis often accompanies peripheral vascular disease and is related to poor tissue perfusion Marrelli, Exercise therapy should be the initial intervention in nondisabling claudication Zafar, Farkouh, Cheebro, Irregularities in coagulation may occur as an effect of therapeutic measures.
Valsalva maneuver increases ICP and potentiates risk of rebleeding.Coronary risk factors and myocardial perfusion in asymptomatic adults: the Multi-Ethnic Study of Atherosclerosis (MESA).
J Am Coll Cardiol. ; – 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.
Nursing Care Plan for Ineffective Tissue Perfusion - Free download as Word Doc .doc), PDF File .pdf), Text File .txt) or read online for free.
Scribd is the world's largest social reading and publishing site/5(3). 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. 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. 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).Download