Nurseslabs » ineffective tissue perfusion

5 Coronary Artery Disease Nursing Care Plans

NursesLabs — Fri, 03 Feb 2012 18:19:49 +0000

Coronary artery disease (CAD) is a condition in which plaque builds up inside the coronary arteries. These arteries supply your heart muscle with oxygen-rich blood. Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. Plaque narrows the arteries and reduces blood flow to your heart muscle. It also makes it more likely that blood clots will form in your arteries. Blood clots can partially or completely block blood flow. When your coronary arteries are narrowed or blocked, oxygen-rich blood can’t reach your heart muscle. This can cause angina or a heart attack. Without quick treatment, a heart attack can lead to serious problems and even death.

CAD is the most common type of heart disease. Lifestyle changes, medicines, and/or medical procedures can effectively prevent or treat CAD in most people. Other names for Coronary Artery Disease are Atherosclerosis, Coronary heart disease, Hardening of the arteries, Heart disease, Ischemic heart disease, and Narrowing of the arteries.

1 Decreased Cardiac Output

Cad causes narrowing of blood vessels. This condition leads to intense pressure exerted on the walls of the blood vessels. The body’s compensatory mechanism is to increase the work load of the heart and thus the patient has decreased cardiac output.

Assessment

Nursing diagnosis

Scientific explanation

Planning

Nursing interventions

Rationale

Expected outcome

S= ∅O=The patient may manifest:

>restlessness

>increased bp

> cold clammy skin

>decreased peripheral pulses

Decreased cardiac output r/t increased vascular resistance

Cad causes narrowing of blood vessels. This condition leads to intense pressure exerted on the walls of the blood vessels. The body’sCompensatory mechanism is to increase the work load of the heart and thus the patient has decreased cardiac output.

Short term:After 2-3 hours of nursing interventions, the patient will verbalize understanding of disease process.Long term:

After two days of nursing interventions the patient will participate in activities to decrease in the heart’s workload

> assess patient’s condition> monitor and record vital signs> encourage patient to verbalize concerns

> encourage patient to change position every two hours

> encourage patient to do relaxation techniques

> encourage patient to engage in divertional activities such as chatting with family and friends.

> reinforced low salt and low fat diet

> to determine possible prolems> for baseline data> to make client express his feelings

> to improve venous return

> to reduce stress

> to divert attention and help patient lessen experienced pain and anxiety

> to prevent further complications of the disease

Short term:The patient shall have verbalizedUnderstanding of disease process.

Long term:

The patient shall have participated in activities to decrease in the heart’s workload

5 Coronary Artery Disease Nursing Care Plans Original source at: Nurseslabs

3 Placenta Previa Nursing Care Plans

NursesLabs — Wed, 01 Feb 2012 11:00:55 +0000

Placenta praevia (placenta previa AE) is an obstetric complication in which the placenta is attached to the uterine wall close to or covering the cervix. It can sometimes occur in the later part of the first trimester, but usually during the second or third. It is a leading cause of antepartum hemorrhage (vaginal bleeding). It affects approximately 0.5% of all labors.

Read our Placenta Previa Nursing Care Plans below

1 Deficient Fluid Volume

Fluid volume deficit is a state in which an individual is experiencing decreased intravascular, interstitial and/or intracellular fluid. Active Blood Loss or Hemorrhage due to disrupted placental implantation during pregnancy may manifest signs and symptoms of fluid vol. deficient that may later lead to hypovolemic shock and cause maternal and fetal death.

Assessment

Nursing Dx

Planning

Nursing Interventions

Rationale

Expected Outcome

S-O-> Bleeding Episodes (amount, duration)

> Facial Grimace due of Pain

> Complaint of pain

Abdomen soft/hard when palpated

> Manifest Body Weakness

> Low BP

Increased HR

Decreased RR

Fetal HR >120-160 bpm

> Decreased Urine Out

> Increased Urine Concentration

> Pale, Cool Skin

>Increased Capillary Refill

Deficient Fluid Volume r/t Active Blood Loss Secondary to Disrupted Placental Implantation

Short Term:After 4 hours of NI, the pt will verbalize understanding of causative factors.Long Term:

After 4 days of NI, the pt will maintain fluid volume at a functional level AEB individually adequate urinary output and stable vital signs.

1. Establish Rapport2. Monitor Vital Signs3. Assess color, odor, consistency and amount of vaginal bleeding; weigh pads

4. Assess hourly intake and output.

5. Assess baseline data and note changes. Monitor FHR.

6. Assess abdomen for tenderness or rigidity- if present, measure abdomen at umbilicus (specify time interval)

7. Assess SaO2, skin color, temp, moisture, turgor, capillary refill (specify frequency)

8. Assess for changes in LOC: note for complaints of thirst or apprehension

9. Provide supplemental O2 as ordered via facemask or nasal cannula @ 10-12 L/min.

10. Initiate IV fluids as ordered (specify fluid type and rate).

11. Position Pt. in supine with hips elevated if ordered or left lateral position.

12. Monitor lab. Work as obtained: Hgb & Hct, Rh and type, cross match for 2 units RBCs, urinalysis, etc. Scheduled for ultrasound as ordered.

1. To gain patient’s trust2. To obtain baseline data3. Provides information about active bleeding versus old blood, tissue loss and degree of blood loss

4. Provides information about maternal and fetal physiologic compensation to blood loss

5. Assessment provides information about possible infection, placenta previa or abruption. Warm, moist, bloody environment is ideal for growth of microorganisms.

6. Detecting increased in measurement of abdominal girth suggests active abruption

7. Assessment provides information about blood vol., O2 saturation and peripheral perfusion

8. To detect signs of cerebral perfusion

9. Intervention increases available O2 to saturate decreased hemoglobin

10. For replacement of fluid vol. loss

11. Position decreases pressure on placenta and cervical os. Left lateral position improves placental perfusion

12. Lab. Work provides information about degree of blood loss; prepares for possible transfusion. Ultra sound provides info about the cause of bleeding

Short Term:The pt shall have verbalized understanding of causative factors.Long Term:

The pt shall have maintained fluid volume at a functional level AEB individually adequate urinary output and stable vital signs.

3 Placenta Previa Nursing Care Plans Original source at: Nurseslabs

14 Cerebrovascular Accident Nursing Care Plans

NursesLabs — Tue, 24 Jan 2012 17:32:40 +0000

Cerebrovascular accident is the sudden death of some brain cells due to lack of oxygen when the blood flow to the brain is impaired by blockage or rupture of an artery to the brain. It is also known as stroke. CVA can be ischemic or hemorrhagic. Hemorrhagic strokes results from a weakened vessel that ruptures and bleeds into the surrounding brain. The blood accumulates and compresses the surrounding brain tissue. The two types of hemorrhagic strokes are intracerebral hemorrhage or subarachnoid hemorrhage. Hemorrhagic strokes have the slowest recovery of all types of stroke.

The nursing goal for patients with stroke can be towards maintaining effective tissue perfusion, preventing further complications, and enhancing coping. This is a nursing care plan for patients with hemorrhagic stroke.

1 Ineffective Cerebral Tissue Perfusion

The presence of partial blockage of the blood vessel can be multifactorial. These can be due to vaso constriction, platelet adherence on rough surface, fat accumulation and therefore decreases elasticity of vessel wall leading to alteration of blood perfusion with the initiation of the clotting sequence. This may later lead to the development of thrombus which can be loosened and dislodged in some areas of the brain such as mid cerebral carotid artery that may lead to alteration of blood perfusion and further develop to cerebral infarct.

NCP- CVA- Ineffective- Tissue- Perfusion

14 Cerebrovascular Accident Nursing Care Plans Original source at: Nurseslabs

5 Benign Febrile Convulsions Nursing Care Plans

NursesLabs — Tue, 24 Jan 2012 17:32:36 +0000

A febrile seizure is a convulsion in a child triggered by a fever. Such convulsions occur without any underlying brain or spinal cord infection or other neurological cause. According to studies, about 3-5% of otherwise healthy children between the ages of 9 months and 5 years will have a seizure caused by a fever. Toddlers are most commonly affected. Most occur well within the first 24 hours of an illness, not necessarily when the fever is highest.

The first febrile seizure is one of life’s most frightening moments for parents. Most parents are afraid that their child will die or have brain damage. Thankfully, simple febrile seizures are harmless. There is no evidence that simple febrile seizures cause death, brain damage, mental retardation, a decrease in IQ, or learning difficulties. (www.nlm.com) However, a very small percentage of children go on to develop other seizure disorders such as epilepsy later in life.

See all our nursing care plans here

1 Hyperthermia

Benign Febrile Convulsion is a convulsion triggered by a rise in body temperature. Fever is not an illness and is an important part of the body’s defense against infection. Antigens or microorganisms cause inflammation and the release of pyrogens which is a substance that induces fever.

Assessment

Nursing Diagnosis

Planning

Nursing Interventions

Rationale

Expected Outcome

Subjective:

Objective:

the patient manifested:

> febrile temp = 39°C

>flushed skin and warm to touch

> convulsion

> RR = 34 bpm

the patient may manifest:

> high fever

> weakness

Hyperthermia

Short term:

After 4 hours of nursing interventions, the patient’s temperature will decrease from 39°C to normal range of 36.5°C to 37°C.

Long Term:

After 2 days of nursing interventions, the patient will be able to be free of complications and maintain core temperature within normal range.

>Assess underlying condition and body temperature.

>Monitor and recorded vital signs.

>Remove unnecessary clothing that could only aggravate heat.

>Promote adequate rest periods.

>Provide TSB

>Advise to increase fluid intake.

>Loosen clothing.

>Administer IV fluids at prescribed rate. Monitor regulation rate frequently.

>Administer antipyretics as ordered.

>To obtain baseline date.

>To note for progress and evaluate effects of hyperthermia.

>To decrease or totally diminish pain.

>Reduces metabolic demands or oxygen.

>To promote surface cooling.

>To help decrease body temperature.

>To provide proper ventilation and promote release of heat through evaporation.

>To promote fluid management.

> Antipyretics lower core temperature.

Short term:

The patient’s temperature shall have decreased from 39°C to normal range of 36.5°C to 37°C.

Long Term:

The patient shall have been able to be free of complications and maintain core temperature within normal range.

5 Benign Febrile Convulsions Nursing Care Plans Original source at: Nurseslabs

Acute Pyelonephritis Nursing Care Plans

NursesLabs — Mon, 09 Jan 2012 17:01:24 +0000

Kidney infection (pyelonephritis) is a specific type of urinary tract infection (UTI) that generally begins in your urethra or bladder and travels up into your kidneys. A kidney infection requires prompt medical attention. If not treated properly, a kidney infection can permanently damage your kidneys or spread to your bloodstream and cause a life-threatening infection. Kidney infection treatment usually includes antibiotics and often requires hospitalization (Mayo Clinic).

This post contains 4 nursing care plans regarding acute pyelonephritis.

Ineffective Renal Tissue Perfusion

Capillaries are an integral part of the nephrons which are responsible for oxygenation. When the nephrons are destroyed or impaired such as in the progress of a renal disease like Pyelonephritis, there will be progressive decline in kidney perfusion. This hypoperfusion affects the kidney’s production of erythropoietin factor responsible for the production of RBC. A decreased in RBC levelproduction will then result to decreased oxygen supply to the kidney

Hyperthermia

In response to infection, inflammatory mediators and neutrophils are activated which will travel to the infected area via increased blood flow and chemotaxis. WBCs, particularly neutrophils, migrate into the site to perform phagocytosis. Neutrophils immediately die after performing their function, and release pyrogens. Pyrogens stimulate fever by increasing heat production and conservation. Fever stimulates immune system activity and kills microorganisms

Acute Pain

As the chemical mediators are released in response to infection, increased renal blood flow and infiltration of WBCs occur in the infected area. These stretch the renal capsule which irritates the nerve endings in the area, causing the activation of pain receptors. The location of the pain is attributed to the retroperitoneal anatomic site of the kidney.

Impaired Urinary Elimination

The entry of microorganisms in the urinary tract triggers the defenses built in our urinary system. One of these is an increase in urine production. The urine flow flushes / washes away microorganisms present in the tract. When the bladder detects the microbes, bladder wall irritation occurs. The bladder contracts its smooth muscles to eradicate the pathogens along with the urine.

Conclusion

Nursing goal should be towards preventing further infection, managing pain, and establishing effective urinary elimination. Hope you’ve found this post useful, if you do, please subscribe and enter your email address below, or you can also drop a comment, thanks for reading!

Acute Pyelonephritis Nursing Care Plans Original source at: Nurseslabs

5 Chronic Renal Failure Nursing Care Plans

NursesLabs — Wed, 21 Dec 2011 17:07:58 +0000

Chronic or irreversible, renal failure is a progressive reduction of functioning renal tissue such that the remaining kidney mass can no longer maintain the body’s internal environment. CRF can develop insidiously over many years, or it may result from an episode of a cure renal failure from which the client has not recovered.

The nursing goal for client’s with CRF is to prevent further complications and supportive care. Client education is also critical as this is a chronic disease and thus requires long-term treatment.

1 Fluid Volume Excess

Renal disorder impairs glomerular filtration that resulted to fluid overload. With fluid volume excess, hydrostatic pressure is higher than the usual pushing excess fluids into the interstitial spaces. Since fluids are not reabsorbed at the venous end, fluid volume overloads the lymph system and stays in the interstitial spaces leading the patient to have edema, weight gain, pulmonary congestion and HPN at the same time due to decrease GFR, nephron hyperthrophized leading to decrease ability of the kidney to concentrate urine and impaired excretion of fluid thus leading to oliguria/anuria.

Fluid- Volume- Excess- CRF

5 Chronic Renal Failure Nursing Care Plans Original source at: Nurseslabs

2 Dengue Hemorrhagic Fever Nursing Care Plans

NursesLabs — Wed, 21 Dec 2011 17:07:56 +0000

Dengue is transmitted by the bite of an Aedesmosquito infected with any one of the four dengue viruses. It occurs in tropical and sub-tropical areas of the world. Symptoms appear 3—14 days after the infective bite. Dengue fever is a febrile illness that affects infants, young children and adults.

Symptoms range from a mild fever, to incapacitating high fever, with severe headache, pain behind the eyes, muscle and joint pain, and rash. There are no specific antiviral medicines for dengue. It is important to maintain hydration. Use of acetylsalicylic acid (e.g. aspirin) and non steroidal anti-inflammatory drugs (e.g. Ibuprofen) is not recommended.

Dengue haemorrhagic fever (fever, abdominal pain, vomiting, bleeding) is a potentially lethal complication, affecting mainly children. Early clinical diagnosis and careful clinical management by experienced physicians and nurses increase survival of patients.

Ineffective Tissue Perfusion

A mosquito which carries the dengue virus is called Aedes aegypti. The said mosquito comes in contact with a person and bites the person. The dengue virus will flow through the blood stream and destroys blood components. Patients with dengue often has decreased WBC, platelet & haemoglobin count. Hemoglobin count is used to measure oxygen carrying capacity of the blood. Hemoglobin carries oxygen. Therefore, if there is decreased haemoglobin, there is also decreased oxygen that reaches the different tissues of the body.

Assessment

Nursing Diagnosis

Objectives

Nursing Interventions

Rationale

Expected Outcome

Subjective:

(none)

Objective:

Decreased WBC

Decreased platelet

Decreased HgB

Decreased capillary refill time

Dysrhythmias

Altered LOC

Fever

Chills

Diaphoresis

Ineffective tissue perfusion related to decreased HgB concentration in the blood secondary to DHF 1

Short Term:

After 4 hours of NI, the pt will demonstrate behaviours to improve circulation.

Long Term:

After 4 days of NI, the pt will demonstrate increased perfusion as appropriate

Establish Rapport

Monitor Vital Signs

Assess patient’s condition

Note customary baseline data

Determine presence of dysrhythmias

Perform blanch test

Check for Homan’s sign

Note presence of bleeding

Elevate HOB

Encourage quiet & restful atmosphere

Instruct to avoid tiring activities

Encourage light ambulation

Encourage use of relaxation techniques

Administer medications

To gain pt’s trust

To obtain baseline data

To assess contributing factors

For comparison with current findings

To identify alterations from normal

To identify / determine adequate perfusion

To determine presence of thrombus formation

To determine risk of anemia

To promote circulation

To promote comfort & decrease tissue O₂ demand

To decrease cardiac workload

To enhance venous return

To decrease tension and anxiety level

To treat underlying cause

The pt shall have demonstrated behaviours to improve circulation

The pt shall have demonstrated increased perfusion as appropriate

Hyperthermia

When a person comes in contact with a mosquito, Aedes aegypti, the dengue virus flows through the blood stream. As the compensatory mechanism of the body, it will raise its temperature to allow the immune system to work better and to deteriorate the condition of the invaders thus causing hyperthermia.

Assessment

Nursing Diagnosis

Objectives

Nursing Interventions

Rationale

Expected Outcome

S> (none)

> Temp of 39.8

> Flushed skin

> Skin warm to touch

> Chills

The pt. May manifest

> Increased RR

> Tachycardia

> Convulsions

> Sweating

Hyperthermia

Short Term:

After 4 hours of NI, pt’s temperature will decrease from 39.8 to 37.

Long Term:

After 3 days of NI, the pt will identify underlying factors & importance of treatment as well as s/sx requiring further evaluation or intervention

Establish Rapport

Monitor Vital Signs

Assess neurologic response, note LOC & orientation, reaction to stimuli, papillary reactions & presence of seizures

Note presence / absence of sweating

Wrap extremities with bath towels

Provide TSB q 15 minutes

Apply local ice packs in axilla

Instruct client to have bed rest

Instruct client to increase OFI

Administer replacement fluids

Administer antipyretics

Reassess temperature q 15 minutes

To gain pt’s trust

To obtain baseline data

To evaluate effects & extent of hyperthermia

To monitor heat & fluid loss

To minimize shivering

To reduce body temperature

To reduce body temperature in areas of high blood flow

To reduce metabolic demands / oxygen consumption

To prevent dehydration

To support circulating blood volume and tissue perfusion

To restore normal body temperature

To determine effectiveness of interventions done

The pt shall have a decreased body temperature from 39.8 to 37

The pt shall have identified underlying factors and importance of treatment as well as s/sx requiring further evaluation or intervention

Source: WHO> Dengue

Image Source: (1) (2)

2 Dengue Hemorrhagic Fever Nursing Care Plans Original source at: Nurseslabs

5 Neonatal Sepsis Nursing Care Plans

NursesLabs — Sat, 12 Nov 2011 12:37:34 +0000

Neonatal Sepsis is an infection in the blood that spreads throughout the body and occurs in a neonate. Neonatal Sepsis is also termed as Neonatal Septicemia and Sepsis Neonatorum. Neonatal Sepsis has 2 types: The one that is seen in the first week of life is termed as Early- onset sepsis and most often appears in the first 24 hours of life.

The infection is often acquired from the mother. This can be cause by a bacteria or infection acquired by the mother during her pregnancy, a Preterm delivery, Rupture of membranes (placenta tissue) that lasts longer than 24 hours, Infection of the placenta tissues and amniotic fluid (chorioamnionitis) and frequent vaginal examinations during labor. The second type or the Late-onset Sepsis is acquired after delivery. This can be cause by contaminated hospital equipment, exposure to medicines that lead to antibiotic resistance, having a catheter in a blood vessel for a long time, staying in the hospital for an extended period of time.

This post has 5 neonatal sepsis nursing care plans

Signs and symptoms of Neonatal Sepsis includes but is not limited to: body temperature changes, breathing problems, diarrhea, low blood sugar, reduced movements, reduced sucking, seizures, slow heart rate, swollen belly area, vomiting, yellow skin and whites of the eyes (jaundice). Possible complications are disability and worst is death of the neonate.

1 Hyperthermia

Due to the presence of an infectious agents, stimulation of the monocytes triggers the release of the pyrogenic cytokines that stimulate anterior hypothalamus which results in elevated thermoregulatory set point that leads to an increased heat conservation (Vasoconstriction) and increased heat production which results to fever.

Assessment

Nursing Diagnosis

Planning

Intervention

Rationale

Expected Outcome

Subjective: May manifest:

Irritability
Weakness

Objective:

The patient may manifest one or more of the following:

Temperature above normal level (36 ^oC)
Skin warm to touch
Presence of tachycardia (above 160 bpm)
Presence of tachypnea (above 60 bpm)
WBC elevated

Hyperthermia related to inflammatory process/ hypermetabolic state as evidenced by an increase in body temperature, warm skin and tachycardia

Short-term:After 30 minutes of nursing intervention the patient will maintain normal core temperature as evidenced by vital signs within normal limits and normal WBC levelLong Term:After 3 days of NI, pt will still maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.

Independent1. Monitor neonate’s condition.2. Monitor Vital signs3. Provide TSB

Interdependent

4. Ensure that all equipment used for infant is sterile, scrupulously clean. Do not share equipment with other infants

Dependent

5. Administer Anti-pyretics as ordered

1. To determine the need for intervention and the effectiveness of therapy.2. To have a baseline data3. Helps in lowering down the temperature4. this would prevent the spread of pathogens to the infant from equipment

5. aids in lowering down temperature

The patient shall maintain normal core temperature as evidenced by normal vital signs and normal laboratory results.

5 Neonatal Sepsis Nursing Care Plans Original source at: Nurseslabs