Saturday, January 26, 2013

Ineffective Tissue Perfusion: Peripheral related to impaired circulation

Ineffective Tissue Perfusion: Peripheral related to impaired circulation

Nursing Diagnosis for Atherosclerosis : Ineffective Tissue Perfusion: Peripheral related to impaired circulation

Goal: clients show improvement perfusion with

Expected outcomes: a peripheral pulse / same, normal skin color and temperature, an increase in behaviors that increase tissue perfusion.

Intervention and Rational:

1. Observation of skin color on the sick.
Rationale: The skin color typically occurs when cyanosis, cold skin. During the color change, the sick to be cool then throbbing and tingling sensations.

2. Note the decrease in pulse; traffic change skin (no color, glossy / tense).
Rationale: This change indicates progress or chronic process.

3. View and examine the skin for ulceration, lesions, gangrene area.
Rationale: Lesions may occur from the size of a pin needle to involve all the fingertips and can lead to infection or damage / loss of tissue seriously.

4. Advise for the proper nutrients and vitamins.
Rationale: The balance of a good diet includes protein and adequate hydration, necessary for healing of the sick.

5. Monitor signs of tissue perfusion adequacy.
Rationale: To identify the early signs of impaired perfusion.

6. Encourage patients perform the exercises or exercises gradually extremities.
Rationale: For circulation.

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