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NCP Ineffective Tissue Perfusion
NCP Ineffective Tissue Perfusion
NURSING
ASSESSMENT INFERENCE GOAL INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
INDEPENDENT:
OBJECTIVE: Ineffective Due to SHORT-TERM: Affecting systemic SHORT-TERM:
Cyanotic tissue decreased After 8 hours of nursing Note current situation circulation/perfusio GOAL FULLY MET
lips perfusion r/t cardiac output, interventions, or presence of n After 8 hours of nursing
Pale decreased there is patient(guided by the conditions that can To identify client at interventions, patient was
conjunctiva cardiac decreased mother) will be able to affect perfusion to all higher risk for able to demonstrate
and nail output preload and demonstrate behaviors to body systems(CHD venous stasis, behaviors to improve
beds stroke volume improve circulation, as DORV with PS) vessel wall injury circulation, as evidence
Weak thus there is evidence by: Identify presence of and by:
peripheral decreased Engage foot-ankle high risk hypercoagulability.. Engage foot-ankle
pulses blood pumped exercises factors(problem in To determine exercises
Cold out from the Use of pressure coronary circulation) adequacy of Use of pressure
clammy skin blood. relieving Measure capillary refill systemic circulation relieving
Dry, scaly Decrease in devices(foam Inspect lower That often devices(foam
skin stroke volume padding) extremities for skin accompany padding)
Decreased decreases Changes position at texture(lack of hair, dry diminished Changes position
skin turgor perfusion timed intervals and scaly) peripheral at timed intervals
>4 seconds throughout the circulation
Decrease body.
capillary
refill 4
seconds
LONG-TERM: LONG-TERM:
After 2 days of nursing DEPENDENT PARTIALLY MET
interventions, patient will To promote optimal After 2 days of nursing
be able to demonstrate Administer KCL and interventions, patient was
ABG(respira increased perfusion, as Ferrous Sulfate blood flow, organ able to demonstrate
tory evidence by: prefusion, and increased perfusion, as
alkalosis) Warm skin COLLABORATIVE: function evidence by:
Moist, smooth skin Warm skin
Collaborate in
Peripheral pulses To maximize Peripheral pulses
CBC(Decre treatment of underlying systemic circulation
present and strong present and strong
conditions(cardiopulmo
ase Normal skin turgor and organ Normal skin turgor
nary conditions)
hemoglobin + 2 seconds perfusion Normal capillary
Refer to dietician
and Normal capillary refill <2
hematocrit) refill <2 seconds For well-balanced, seconds(not met)
Normal ABG result low saturated-fat, Normal ABG
CBC(Hemoglobin low cholesterol diet result(not met)
and hematocrit and other CBC(Hemoglobin
within normal limits) modifications as and hematocrit
indicated. within normal
limits)