Ineffective Tissue Perfusion NCP

Calata, Jasmin Joy G.
BSN218-Group 72
NURSING CARE PLAN
Nursing
Problem
Cues
Ineffective
cerebral perfusion
related to
interruption of
blood flow
Subjective:
Highblood siya
Nahihilo nga kaya
dinala namin ditto
Objectives:
- patient is
lethargic when
brought to ER;
-cold skin
temperature
-Capillary refill >3
sec
-pale nail beds and
palms
-pale conjunctiva
-with body
Analysis
Situational:
Patient is male, 51 years
old, obese, and is
hypertensive. Blood
pressure monitored to as
180/120mmHg upon
admission and is lethargic.
Scientific:
Inadequate tissue perfusion
can be a diagnosis, a sign
and a symptom that one or
more organs of the body are
beginning to fail due to a
lack of oxygenated blood
either reaching an organ or
fully circulating through an
organ or body system.
(What Is Ineffective Tissue
Perfusion? |
eHow.com http://www.ehow
Goal/Objectives
Nursing
Interventions
Rationale
Evaluation
After 2 days of nursing

intervention, the client will
have improved blood
supply.
Involve the client in

planning, intervention,
assessment of her
condition.
Therapeutic relationship with

someone experiencing illness
may include facilitating the
clients expression of feelings
about her condition, which
imparts a sense of being
cared for; providing support
, reassurance, and
understanding, which allow
the client to develop
confidence in the nurse; and
teaching the client selfmanagement strategies to
promote
cooperation
(Black, J.M. & Hawks J.H.
Medical-Surgical Nursing.
8th ed. pp. 371-372)
EFFECTIVENESS
After 2 hours of nursing

intervention, the patient
will be able to:
a. Verbalize
understanding of
condition, therapy
regimen.
b. Demonstrate
behaviour changes
to improve
circulation
c. Demonstrate
increased perfusion
as individually
appropriate.
Determine factors
related to decreased
cerebral perfusion and
Influence choice of
interventions. Deterioration
in neurological signs may
Was the client able

to initiate therapeutic
relationship with the
client
Yes___No__Why?
Was the client able

to have Increased
function of
compensatory body
part?
Yes___No__Why?
Was the client be

able to prevent
complications?
weakness
- uncooperative
-presence of pedal
edema
- BP =
180/120mmHg;
HR= 75bpm
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Health Implication:
Based on the observation,
the patient is paralyzed, and
has had stroke. With this
condition, it could have an
impact both on the patient
and family as well. Since
the patient is still in the
viable stage of working, she
is probably to stop on it and
lesser family income would
be adopted. She would also
be dependent in physical
and financial aspect on her
family. Psychological and
emotional burden could be
experienced by the family
members.
Also, impaired tissue
infusion over a prolonged
period can lead to serious
complications like organ
failure.
potential to increased
intracranial pressure.
reflect decrease intracranial

adaptive activity.
(http://www.enursecareplan.com)
Monitor/Document
neurological status
frequently and compare
with baseline.
Assess trends in level of

consciousness and increased
ICP and is useful in
determining the extent and
progression of CNS damage.
Monitor vital signs esp.

blood pressure.
Evaluate pupils, noting

size, shape, equality,
and light reactivity.
Discuss avoiding
exposures to cold and
dressing warmly.
Yes___No__Why?
EFFICIENCY
Were resources
available to the nurse
and client
maximized?
Hypertension may have been

a precipitating factor.
Yes___No___Why?
Pupil reactions are regulated

by Oculomotor (III) cranial
nerve and are useful in
determining if the brainstem
is intact.
Were interventions
appropriate to client
situation? (meaning
age, health
condition, etc.)
Wear socks and gloves; use

cotton/flannel bed clothing,
wear socks to bed. Natural
ACCEPTABILITY
APPROPRIATENE
SS
Yes___No___Why?
Were all
fibers retain heat more

efficiently.
(Doenges, M. et. Al Nursing
Care Plans, 1984)
interventions
acceptable to the
client?
Yes___No___Why?
Encourage use of
warm, moist packs,
baths and temps by
explaining correct use
and safety procedures.
Avoid use of
constricting clothing.
Provide restful, quiet

environment.
Increases temperature and

adds to patient comfort. With
decreased sensation, careful
safety measures must be used
to prevent tissue damage.
Care Plans, 1984)
Tight clothing has a

tourniquet effect on
circulation, inhibiting flow
and may result in pooling of
blood and edema dependent
issues. Muscle action
facilitates venous return.
Care Plans, 1984)
Minimize stress that

stimulates a vasoconstrictor
response.
Care Plans, 1984)
ADEQUACY
Were the numbers of
interventions enough
to solve the health
problem?
Yes___No___Why?
Encourage passive
ROM.
Promotes circulation and

formation of collateral flow.
Care Plans, 1984)
Elevate head of bed

approximately 6 inches
at night.
Increases gravitational blood

flow.
Care Plans, 1984)
Observe and record

pallor, cyanosis,
ulcerations, pulse
deficits, bruits,
temperature of the skin,
and distention of vein.
Symptomatology is
dependent on degree of
ischemia/obstruction present.
Pallor of foot on elevation
indicates ischemia. After
elevation, feet in dependent
position should have normal
color return in 10 seconds.
Care Plans, 1984)
Observe for epistaxis,

ecchymosis, hematuria,
black and tarry stools.
May need interventions to

reverse anticoagulation
effects.
Care Plans, 1984)
Check distal pulses
If patient has had recent
motion and sensation.
femoral/popliteal or
aortic/iliac graft to improve
circulation, absence of pulse
may indicate thrombosis of
graft or obstruction by
mechanical means.
Care Plans, 1984)
MEDICAL
MANAGEMENT
Oscillating bed.
Provides passive assistance

to circulation.
Care Plans, 1984)
Administer medications
as ordered.
Certain medications would

improve the circulation
especially if thrombus
formation is present e.g.
Coumadin, warfarin, etc.
Care Plans, 1984)

Ineffective Tissue Perfusion NCP

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Calata, Jasmin Joy G.

After 2 days of nursing

Involve the client in

Therapeutic relationship with

After 2 hours of nursing

Was the client able

Was the client able

Was the client be

reflect decrease intracranial

Assess trends in level of

Monitor vital signs esp.

Evaluate pupils, noting

Hypertension may have been

Pupil reactions are regulated

Wear socks and gloves; use

fibers retain heat more

Provide restful, quiet

Increases temperature and

Tight clothing has a

Minimize stress that

Promotes circulation and

Elevate head of bed

Increases gravitational blood

Observe and record

Observe for epistaxis,

May need interventions to

Check distal pulses

If patient has had recent

motion and sensation.

Provides passive assistance

Certain medications would

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