Custom Search

NCP for Ineffective Tissue Perfusion related to Heart Failure

 |  in Nursing Interventions at  3:14 PM


Nursing Diagnosis for Heart Failure : Ineffective Tissue Perfusion related to decrease in cardiac output, tissue hypoxemia, acidosis and possible thrombus or embolism.

Definitions:
Decreased oxygen delivery, the failure to feed the tissue at the capillary level.

Defining characteristics:

Renal :
  • Changes in blood pressure beyond the limits of the parameters.
  • Hematuria.
  • Oliguria / anuria.
  • Elevation / decrease in BUN / creatinine ratio.
Gastrointestinal :
  • Intestinal hypoactive or absent.
  • Nausea.
  • Abdominal distention.
  • Abdominal pain or does not feel soft (tenderness).
Peripheral :
  • Edema.
  • Positive Homan's sign.
  • Changes in skin characteristics (hair, nails, water / moisture).
  • The pulse is weak or non-existent.
  • Discoloration of the skin.
  • Changes in skin temperature.
  • Changes in sensation.
  • Bluish.
  • Changes in blood pressure in the extremities.
  • Bruit.
  • Too late to recover.
  • Reduced arterial pulsation.
  • Pale skin color in elevation, the color does not return to the decrease in the foot.

Cerebral:
  • Abnormalities talk.
  • Limb weakness or paralysis.
  • Changes in mental status.
  • Changes in the motor response.
  • Changes in pupil reaction.
  • Difficulty in swallowing.
  • Changes in habits.
Cardiopulmonary :
  • Changes in the frequency of respiration beyond the limits of the parameters.
  • The use of additional respiratory muscles.
  • Turn over three second capillary (capillary refill).
  • Abnormal arterial blood gases.
  • The feeling of "impending Doom" (Fate threatened).
  • Bronchospasm.
  • Dyspnea.
  • Arrhythmias.
  • Nose redness.
  • Chest retraction.
  • Chest pain.

Related Factors :
  • Hypovolemia.
  • Hypervolaemia.
  • Arterial flow was interrupted.
  • Exchange problems.
  • Venous flow is cut off.
  • Hypoventilation.
  • Mechanical reduction in venous or arterial blood flow.
  • Damage to transport oxygen through the alveolar and capillary membranes.
  • Not comparable between ventilation with blood flow.
  • Poisoning enzyme.
  • Changes in affinity / binding O2 with Hb.
  • The decline in Hb concentration in the blood.

NOC:
  • Circulation status.
  • Tissue Perfusion: cerebral.
Outcomes:
a. Demonstrating circulation status, which is characterized by:
  • Systole and diastole the pressure within the expected range.
  • No orthostatic hypertension.
  • No signs of increased intracranial pressure (no more than 15 mm Hg).
b. Demonstrating cognitive ability, which is characterized by:
  • Communicate clearly and in accordance with ability.
  • Shows attention, concentration and orientation.
  • Process the information.
  • Making the correct decision.
c. Showed intact cranial sensorimotor functions: level of consciousness improved, there is no involuntary movements.


NIC:

Peripheral Sensation Management.
  • Monitor the presence of certain areas only sensitive to heat / cold / sharp / blunt.
  • Monitor the presence of paresthesia.
  • Instruct family to observe the skin, if there are lesions or lacerations.
  • Use gloves for protection.
  • Limit movement of the head, neck and back.
  • Monitor the ability of defecation.
  • Collaboration of analgesic.
  • Monitor the presence of thrombophlebitis.
  • Discuss about the causes of changes in sensation.

Custom Search

Recent Posts

Google+ Followers

Powered by Blogger.
Proudly Powered by Blogger.