1.

Ineffective Cardiopulmonary Tissue Perfusion

Assessment Nursing Diagnosis Rationale Goals & Objectives Nursing Rationale Evaluation
Interventions
Subjective: Ineffective If the heart and lungs are After 30 minutes of >Encourage quiet, *To conserve energy After 3 hrs of nursing
>Report of dyspnea even Cardiopulmonary Tissue congested, there would nursing intervention, restful and peaceful & ↓ body tissue O2 intervention, the goal
at rest Perfusion secondary to be excess fluid in these these should manifest: environment demand. was partially met as
>Palpitation impaired transport of mentioned areas. If manifested by:
>Chest pain at 6/10 pain oxygen there’s an excess fluid >Relief of dyspnea >Inform client to *It increases cardiac
scale
or blood, they will without the use of avoid activities; like, workload >Relief from dyspnea
Objective: (NANDA, 2009) compete for accessory muscles straining at stool and breathing
>Use of accessory oxygenation in the lungs >↓ Chest Pain Scale normally without the
muscles when breathing resulting to from 6 to 1-4/10 >Always monitor the *Hypertension can use of accessory
>Poor capillary refill unoxygenated blood; >Skin normal in color blood pressure damage blood vessel muscles
(>5s) thus impairing the >have a stable vital & organ function >Chest Pain scale of
>Pale skin transport of oxygen for signs of BP=100/70- >Encourage use of *To decrease tension 4/10
>Pale mucous membrane the perfusion of body 140/80mmHg relaxation techniques level >Skin pale in color
>↓Hgb of 139 g/L tissues and cells. PR=60-100bpm >Vital Signs of
>Hct of 0.42 Unoxygenated blood RR=12-20cpm >Position patient in *To promote optimal 130/80mmHg,
>041510: 2-D Echo result won’t be able to perfuse semi to high fowler’s lung expansion & 93bpm and 18 cpm
shows Mild Tricuspid
the heart and lung tissue position decreases cardiac
Regurgitation and
impaired diastrolic workload
relaxation of Left (Brunner and Suddhart’s
ventricle Medical-Surgical >Encourage deep *To promote lung
>RR of 23cpm Nursing) breathing exercises expansion
PR of 104bpm
BP of 150/100mmHg