9. Ineffective Peripheral Tissue Perfusion - Mastectomy Nursing Care Plans
The importance of lymphatic system in maintaining fluid balance in the body. The plasma filters into the interstitial spaces from blood flowing through the capillaries. Much of this interstitial fluid is absorbed by tissue cells or reabsorbed by the blood before it flows out of the tissue. A small amount of interstitial fluid is left behind. If this would continue over even a brief period of time, the increased interstitial fluid would cause massive edema. This edema would causes tissue destruction or death This problem is avoided by the presence of lymphatic vessels that act as “drains” to collect the excess fluid and return it to the venous blood just before it reaches the heart.
NDx: Ineffective tissue perfusion (lymphedema) r/t compromised flow of lymphatic fluid
Assessment | Desired Goal | Nursing Interventions | Rationale | Expected outcome |
SO OThe patient may manifest:
=weak pulses = edema = drowsiness = altered sensations = changes in LOC | Short Term: After 3-4 hours of nursing interventions, the patient will be able to demonstrate relaxation techniques.
Long Term: After 3-4 days of nursing interventions, the patient will be able to demonstrate an improved perfusion by regaining strength, strong pulse and maintain alertness. | 1. establish rapport
2. monitor and record VS
3.assess signs of decreased tse perfusion
4. identify changes related to systemic or peripheral alterations in circulation.
5. evaluate signs of infection when immune system is compromised
6. observe for signs of pulmonary emboli.
7. assess lower extremities, noting skin texture, presence of edema, ulcerations
8. encourage early ambulation if possible
9. elevate HOB
10. Provide quiet, relaxing environment
11. caution pt to avoid activities that could increase cardiac workload.
12. teach relaxation techniques like deep breathing
13. encourage pt. to rest
14. position pt. on a semi-fowler’s position
15. keep environment allergen free for the pt.
16. educate on proper hand washing
17. encourage pt. to eat nutritious foods | 1. to gain pt’s trust
2. to have a baseline data
3. to plan for effective treatment and give prompt care.
4. to asses predisposing factors
5. to determine other possible related factors.
6. to assess for contributing factors
7. to note degree of impairment involved
8. to enhance venous return
9. to increase gravitational blood flow
10. To prevent additional stress to pt.
11. to maximize tse perfusion
12. to facilitate rest and recuperation and proper oxygenation
13. to enable the body to recuperate and repair
14. to facilitate proper chest expansion
15. to prevent presence which may cause increased mucus secretion
16. to prevent infection
17. to meet daily caloric requirement and facilitate repair with body tissue | Short Term: Patient shall able to demonstrate relaxation techniques
Long Term: Patient shall able to demonstrate an improved perfusion by regaining strength, strong pulse and maintain alertness. |
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