FOCUS/ Nursing Expected Outcome (of PLAN (Nursing Rationale

Diagnosis PRIORITY diagnosis) Interventions)

Ineffective Tissue After the end of the 8  Assess and  This will serve
Perfusion hour span of care the pt monitor vital as the baseline
will: signs data.

A. ) demonstrate  Assess for  There are

increased perfusion as signs of specific
evidenced by absence of decreased clusters of
edema tissue symptoms that
perfussion can have a
B.) verbalize of variety of
understanding of risk origins.
factors or Evaluation of
condition,therapy the
regimens ,side effects characteristics
medications ,and when to of ineffective
contact healthcare tissue
provider perfusion
establishes a
baseline for
subsequent
comparison.

 Use pulse  To detect

oximeter to changes in
monitor oxygenation
oxygen
saturation and
pulse rate

 Check Hgb  Low levels

levels decrease
oxygen
transport to
the tissues and
uptake at the
alveolar-
capillary
membrane.

 Check for  Peripheral

pallor, pulse absence
 cyanosis, needs to be
mottling, cool reported or
or clammy handled right
skin. Assess away. Skin
quality of every perfusion may
pulse be affected,
and pulses
may stop, as a
result of
systemic
vasoconstrictio
n brought on
by decreased
cardiac output.
Assessment is
therefore
necessary for
ongoing
comparisons.

 Performed  Regulate renal

continuous perfusion may
pulse oximetry take place due
to vascular
occlusion.

 Note urine  This ensures

output adequate
perfusion of
vital organs .

 Assist with  Gently

position repositioning
changes patientfrom a
supine to
sitting/standing
position
canreduce the
risk for
orthostatic BP
changes. Older
patients are
more
susceptible to
such drops of
pressure with
position
changes
 Position patient  Upright
properly in a positioning
 semi -Fowler’s promotes
to high - improved
Fowler’s as alveolar gas
tolerated exchange

 Provide  Knowledge of
knowledge on causative
normal tissue factors
perfusion and provides a
possible causes rationale for
of impairment treatments

 Document  To promote
actions taken continuity of
care

 Report patient  To determine

unusualities to further action
physician to be taken