Urinary Elimination Client Outcomes Demonstrates adequate tissue perfusion as evidenced by palpable peripheral pulses, warm and dry skin, adequate urinary output, and the absence of respiratory distress Verbalizes knowledge of treatment regimen, including appropriate exercise and medications and their actions and possible side effects Identifies changes in lifestyle that are needed to increase tissue perfusion NIC Interventions Nursing Interventions Classification Suggested NIC Labels Nursing Interventions and Rationales Cerebral perfusion 1. If client experiences dizziness because of orthostatic hypotension when getting up, teach methods to decrease dizziness, such as remaining seated for several minutes before standing, flexing feet upward several times while seated, rising slowly, sitting down immediately if feeling dizzy, and trying to have someone present when standing. Orthostatic hypotension results in temporary decreased cerebral perfusion. Monitor neurological status; do a neurological examination; and if symptoms of a cerebrovascular accident CVA occur e.
June 28, Nursing Assessment Obtain seizure history, including prodromal signs and symptoms, seizure behavior, postictal state, history of status epilepticus. Obtain history of drug or alcohol abuse.
Assess compliance and medication-taking strategies. Drug Related History Nonadherence to medication regimen as well as toxicity of antiepileptic medications can increase seizure frequency. Obtain drug levels before implementing medication changes. Normal breathing pattern adequate to meet oxygen needs.
Nursing Interventions Airway management Monitor respiratory and oxygenation status to determine presence and extend of problem and to initiate appropriate interventions. Position patient side lying to maximize ventilation potential. Perform endotracheal or nasotracheal suctioning to maintain airway as needed.
Seizure management Loosen clothing to prevent restricted breathing. Apply oxygen as appropriate to maintain oxygenation and prevent hypoxia. Maintaining Cerebral Tissue Perfusion Nursing Interventions Maintain a patent airway until patient is fully awake after a seizure.
Provide oxygen during the seizure if cyanotic changes occurs. Stress the importance of taking medications regularly.
Monitor serum levels for therapeutic range of medications. Monitor patient for toxic adverse effects of medications. Monitor platelet and liver functions for toxicity due to medications.
Preventing Injury Nursing Interventions Provide a safe environment by padding side rails and removing clutter which may be harmful to the patient. Monitor compliance in taking antiseizure medications to determine risk for seizure. Keep suction, Ambu bag,mouth piece at the bedside to maintain airway and oxygenation if needed.
Place the bed in a low position. Do not restrain the patient during a seizure.What's a good care plan example for "ineffective tissue perfusion"?
Moved to the General Nursing Student Discussions forum we have several threads in this forum discussing care plans. but neither of your goals match your ND.
If the problem is ineffective tissue perfusion, your goals should be reflective of adequate tissue perfusion.
Sep 24, · Nanda Care Plan Nursing Diagnosis Interventions. NCP for Ineffective Tissue Perfusion - related to a decrease in the cellular components required for the delivery of oxygen / nutrients to the cells. Characterized by: Capillary refill time (CRT) is more than 3 seconds, cyanosis, pale skin, dry mucous membranes, nails and hair brittle. Jan 12, · Nursing Diagnosis: Ineffective Tissue Perfusion: Peripheral, Renal, Gastrointestinal, Cardiopulmonary, Cerebral NOC Outcomes (Nursing Outcomes Classification) * Assess for signs of decreased tissue perfusion (see Defining Characteristics for each category in this care plan). What's a good care plan example for "ineffective tissue perfusion"? Moved to the General Nursing Student Discussions forum we have several threads in this forum discussing care plans. but neither of your goals match your ND. If the problem is ineffective tissue perfusion, your goals should be reflective of adequate tissue perfusion.
After an hour of nursing interventions, prescribed treatment will be given to promote reduction of persisting symptom. LONG TERM GOAL Within 8hours of nursing interventions, the client's effectiveness of tissue perfusion will be improved. Chronic Renal Failure Nursing Care Plans.
Medical & Surgical Nursing (Notes) Chronic Renal Failure Nursing Care Plans. Facebook; Prev Article Next Article.
Altered Renal Tissue Perfusion. For optimal cell functioning the kidney excrete potentially harmful nitrogenous product-Urea, Creatinine, Uric Acid but because of the loss of kidney.
Nursing care plan and nanda diagnosis for cellulitis. This nursing care plan includes nursing interventions and goals for the patient. NCP for ineffective tissue perfusion related to inflammoratory response secondary to cellulitis.
Jan 12, · * Instruct the patient to inform the nurse immediately if symptoms of decreased perfusion persist, increase or return (see Defining Characteristics of this care plan).
* Provide information on normal tissue perfusion and possible causes for impairment. In the latest edition of nanda nursing diagnosis list (), NANDA International has made some changes to its approved nursing diagnoses compared to the previous edition of NANDA nursing diagnoses (10th edition).