Kapiolani Community College

Associate Degree in Nursing Program

NURS 210 Health Promotion Across the Lifespan
Nursing Care Plan
Student Name: Christina Chow
Date Submitted: 4/5/2013
Concept: Perfusion
Nursing Diagnosis #3 (3 parts) Ineffective Peripheral Tissue Perfusion, related to Atrial Fibrillation, evidenced by diminished peripheral pulses and
crusty brittle nails on lower extremities.
Definition (reference):
Insufficient supply of blood and oxygen to extremities
Scientific Rationale (reference): Lack of perfusion in one area of the body, affects the whole circulatory system.
Short term Outcome
1. Pt lower extremities
will be warm and dry to
the touch & cap refill
will be <3secs during
shift.
Met/Not Met/Ongoing
Long Term
Outcome
1. Pt lower
extremities will be
warm and dry to
touch for next weeks
and cap refill will be

Interventions
(All applicable interventions including
assessment, direct nursing action,
collaborative intervention, teaching)

Rationale (includes reference for each

intervention)

#1. Assess and document presence or absence

and quality of all distal pulses

#1. Risk for arterial occlusion is high. Distal

pulses provide baseline for serial assessments.

Evaluation (patient response, data, for

each intervention).
Continuous action (resolved, continue
intervention, change intervention)

#1. Radial pulses strong and even bilaterally. R

brachial pulse strong and even, L brachial
unable to palpate d/t contracture, cap refill is
brisk <3 sec. Popliteal pulses are strong and
#2. Assess and document skin color and
#2. Knowledge of baseline circulatory status of even bilaterally. Dorsalis and tibialis pulses
temperature, presence or absence of pain,
extremities will assist in monitoring for changes weak.
numbness, tingling, movement, and sensation of post-procedure (Doppler ultrasonic reading)
# 2. Skin warm and dry to touch on upper
all extremities.
extremities. Lower extremities cold and dry to
touch. Pt denies pain and states sensation even
bilaterally on upper and lower extremities.
#3. Do passive ROM exercises q 2-4 hours as
#3. ROM exercises prevent venous stasis and
# 3. Pt able to do full AROM on RUE and RLE.
tolerated
joint stiffness.
L upper extremity is contracted with minimal

<3secs.
Met/Not Met/Ongoing

Note: Gulanick, M. & Myers, J.,

Nursing Care Plans 7th ed., (2011).
Pgs. 302-303

#4. Instruct patient to report presence of pain,

numbness, tingling, and decrease or loss of
sensation and movement immediately.

#4. Pt needs to understand the meaning these

symptoms represent for quick assessment,
diagnosis, and treatment.

ROM. NA applied support device for

contracture, 30 min. Minimal passive ROM of
LLE.
# 4. Informed patient to notify nurse if any
change in sensation or pain.