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NURSING DIAGNOSIS: Tissue Perfusion, risk for ineffective (specify)
Risk factors may include
- Hypovolemia
- Reduction/interruption of blood flow: pelvic congestion, postoperative tissue inflammation, venous stasis
- Intraoperative trauma or pressure on pelvic/calf vessels: lithotomy position during vaginal hysterectomy
Possibly evidenced by
- [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
Desired Outcomes
Tissue Perfusion: (Specify) (NOC)
- Demonstrate adequate perfusion, as evidenced by stable vital signs, palpable pulses, good capillary refill, usual mentation, individually adequate urinary output.
- Be free of edema, signs of thrombus formation.
6 Hysterectomy Nursing Care Plan (NCP)
- Low Self-Esteem — Hysterectomy Nursing Care Plan (NCP)
- Impaired Urinary Elimination — Hysterectomy Nursing Care Plan (NCP)
- Constipation/Diarrhea — Hysterectomy Nursing Care Plan (NCP)
- Ineffective Tissue Perfusion — Hysterectomy Nursing Care Plan (NCP)
- Sexual Dysfunction — Hysterectomy Nursing Care Plan (NCP)
- Knowledge Deficit — Hysterectomy Nursing Care Plan (NCP)
Ineffective Tissue Perfusion — Hysterectomy Nursing Care Plan (NCP): Nursing Interventions & Rationale
| Nursing Interventions | Rationale |
| Monitor vital signs; palpate peripheral pulses, and note capillary refill; assess urinary output/characteristics. Evaluate changes in mentation. | Indicators of adequacy of systemic perfusion, fluid/blood needs, and developing complications. |
| Inspect dressings and perineal pads, noting color, amount, and odor of drainage. Weigh pads and compare with dry weight if patient is bleeding heavily. | Proximity of large blood vessels to operative site and/or potential for alteration of clotting mechanism (e.g., cancer) increases risk of postoperative hemorrhage. |
| Turn patient and encourage frequent coughing and deep-breathing exercises. | Prevents stasis of secretions and respiratory complications. |
| Avoid high-Fowler’s position and pressure under the knees or crossing of legs. | Creates vascular stasis by increasing pelvic congestion and pooling of blood in the extremities, potentiating risk of thrombus formation. |
| Assist with/instruct in foot and leg exercises and ambulate as soon as able. | Movement enhances circulation and prevents stasis complications. |
| Check for Homans’ sign. Note erythema, swelling of extremity, or reports of sudden chest pain with dyspnea. | May be indicative of development of thrombophlebitis/pulmonary embolus. |
| Administer IV fluids, blood products as indicated. | Replacement of blood losses maintains circulating volume and tissue perfusion. |
| Apply antiembolus stockings. | Aids in venous return; reduces stasis and risk of thrombosis. |
| Assist with/encourage use of incentive spirometer. | Promotes lung expansion/minimizes atelectasis. |
Found through:
nursing care plan for chest trauma, nurse care plan for ineffective circulatory system, nursing diagnosis for post tah bso, nursing management of patient with post operative myomectomy
