Silahkan berkunjung keblog saya, semoga bermanfaat bagi kita semua dan dapat memajukan dunia keperawatan.

Nursing Diagnosis: Ineffective Tissue perfusion (specify type): cerebral, renal, cardiopulmonary, GI, peripheral Application of NANDA, NOC, NIC


Nursing Diagnosis: Ineffective Tissue perfusion (specify type): cerebral, renal, cardiopulmonary, GI, peripheral
Betty J. Ackley

NANDA Definition: Decrease in oxygen resulting in failure to nourish tissues at the capillary level

Defining Characteristics:
Renal
Altered blood pressure outside of acceptable parameters; hematuria; oliguria or anuria; elevation in BUN/creatinine ratio
Gastrointestinal
Hypoactive or absent bowel sounds; nausea; abdominal distention; abdominal pain or tenderness
Peripheral
Edema; positive Hoeman's sign; altered skin characteristics (hair, nails, moisture); weak or absent pulses; skin discolorations; skin temperature changes; altered sensations; diminished arterial pulsations; skin color pale on elevation, color does not return on lowering the leg; slow healing of lesions; cold extremities; dependent, blue, or purple skin color
Cerebral
Speech abnormalities; changes in pupillary reactions; extremity weakness or paralysis; altered mental status; difficult in swallowing; changes in motor response; behavioral changes
Cardiopulmonary
Altered respiratory rate outside of acceptable parameters; use of accessory muscles; capillary refill >3 seconds; abnormal arterial blood gases; chest pain; sense of "impending doom"; bronchospasms; dyspnea; dysrhythmias; nasal flaring; chest retraction


Related Factors: Hypovolemia; interruption of arterial flow; hypervolemia; exchange problems; interruption of venous flow; mechanical reduction of venous and/or arterial blood flow; hypoventilation; impaired transport of oxygen across alveolar and/or capillary membrane; mismatch of ventilation with blood flow; decreased hemoglobin concentration in blood; enzyme poisoning; altered affinity of hemoglobin for oxygen

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
·         Circulation Status
·         Cardiac Pump Effectiveness: Tissue Perfusion: Cardiac
·         Tissue Perfusion: Cerebral
·         Tissue Perfusion: Peripheral
·         Fluid Balance
·         Hydration
·         Urinary Elimination
Client Outcomes
·         Demonstrates adequate tissue perfusion as evidenced by palpable peripheral pulses, warm and dry skin, adequate urinary output, and the absence of respiratory distress
·         Verbalizes knowledge of treatment regimen, including appropriate exercise and medications and their actions and possible side effects
·         Identifies changes in lifestyle that are needed to increase tissue perfusion
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
·         Circulatory Care: Arterial Insufficiency
Nursing Interventions and Rationales
Cerebral perfusion
·         If client experiences dizziness because of orthostatic hypotension when getting up, teach methods to decrease dizziness, such as remaining seated for several minutes before standing, flexing feet upward several times while seated, rising slowly, sitting down immediately if feeling dizzy, and trying to have someone present when standing. Orthostatic hypotension results in temporary decreased cerebral perfusion.
·         Monitor neurological status; do a neurological examination; and if symptoms of a cerebrovascular accident (CVA) occur (e.g., hemiparesis, hemiplegia, or dysphasia), call 911 and send to the emergency room. New onset of these neurological symptoms can signify a stroke. If caused by a thrombus and the client receives treatment within 3 hours, a stroke can often be reversed.
·         See care plans for Decreased Intracranial adaptive capacity, Risk for Injury, and Acute Confusion.
Peripheral perfusion
·         Check dorsalis pedis and posterior tibial pulses bilaterally. If unable to find them, use a Doppler stethoscope and notify physician if pulses not present. Diminished or absent peripheral pulses indicate arterial insufficiency (Harris, Brown-Etris, Troyer-Caudle, 1996).
·         Note skin color and feel temperature of the skin. Skin pallor or mottling, cool or cold skin temperature, or an absent pulse can signal arterial obstruction, which is an emergency that requires immediate intervention. Rubor (reddish-blue color accompanied by dependency) indicates dilated or damaged vessels. Brownish discoloration of skin indicates chronic venous insufficiency (Bright, Georgi, 1992; Feldman, 1998).
·         Check capillary refill. Nail beds usually return to a pinkish color within 3 seconds after nail bed compression (Dykes, 1993).
·         Note skin texture and the presence of hair, ulcers, or gangrenous areas on the legs or feet. Thin, shiny, dry skin with hair loss; brittle nails; and gangrene or ulcerations on toes and anterior surfaces of feet are seen in clients with arterial insufficiency. If ulcerations are on the side of the leg, they are usually venous (Bates, Bickley, Hoekelman, 1998).
·         Note presence of edema in extremities and rate it on a four-point scale. Measure circumference of ankles and calf at the same time each day in the early morning (Cahall, Spence, 1995).
·         Assess for pain in extremities, noting severity, quality, timing, and exacerbating and alleviating factors. Differentiate venous from arterial disease. In clients with venous insufficiency the pain lessens with elevation of the legs and exercise. In clients with arterial insufficiency the pain increases with elevation of the legs and exercise (Black, 1995). Some clients have both arterial and venous insufficiency. Arterial insufficiency is associated with pain when walking (claudication) that is relieved by rest. Clients with severe arterial disease have foot pain while at rest, which keeps them awake at night. Venous insufficiency is associated with aching, cramping, and discomfort (Bright, Georgi, 1992).
Arterial insufficiency
·         Monitor peripheral pulses. If new onset of loss of pulses with bluish, purple, or black areas and extreme pain, notify physician immediately. These are symptoms of arterial obstruction that can result in loss of a limb if not immediately reversed.
·         Do not elevate legs above the level of the heart. With arterial insufficiency, leg elevation decreases arterial blood supply to the legs.
·         For early arterial insufficiency, encourage exercise such as walking or riding an exercise bicycle from 30 to 60 minutes per day. Exercise enhances the development of collateral circulation, strengthens muscles, and provides a sense of well-being (Cahall, Spence, 1995). Aerobic exercise training can reverse age-related peripheral circulatory problems in otherwise healthy older men (Beere et al, 1999). Exercise therapy should be the initial intervention in nondisabling claudication (Zafar, Farkouh, Cheebro, 2000).
·         Keep client warm, and have client wear socks and shoes or sheepskin-lined slippers when mobile. Do not apply heat. Clients with arterial insufficiency complain of being constantly cold; therefore keep extremities warm to maintain vasodilation and blood supply. Heat application can easily damage ischemic tissues (Creamer-Bauer, 1992).
·         Pay meticulous attention to foot care. Refer to podiatrist if client has a foot or nail abnormality. Ischemic feet are very vulnerable to injury; meticulous foot care can prevent further injury.
·         If client has ischemic arterial ulcers, see care plan for Impaired Tissue integrity, but avoid use of occlusive dressings. Occlusive dressings should be used with caution in clients with arterial ulceration because of the increased risk for cellulitis (Cahall, Spence, 1995).
Venous insufficiency
·         Elevate edematous legs as ordered and ensure that there is no pressure under the knee. Elevation increases venous return and helps decrease edema. Pressure under the knee decreases venous circulation.
·         Apply support hose as ordered. Wearing support hose helps to decrease edema. Studies have demonstrated that thigh-high compression stockings can effectively decrease the incidence of deep vein thrombosis (DVT) (Brock, 1994).
·         Encourage client to walk with support hose on and perform toe up and point flex exercises. Exercise helps increase venous return, build up collateral circulation, and strengthen the calf muscle pumps (Cahall, Spence, 1995).
·         If client is overweight, encourage weight loss to decrease venous disease. Obesity is a risk factor for development of chronic venous disease (Kunimoto et al, 2001).
·         Discuss lifestyle with client to see if occupation requires prolonged standing or sitting, which can result in chronic venous disease (Kunimoto et al, 2001).
·         If client is mostly immobile, consult with physician regarding use of calf-high pneumatic compression device for prevention of DVT. Pneumatic compression devices can be effective in preventing deep vein thrombosis in the immobile client (Hyers, 1999)
·         Observe for signs of deep vein thrombosis, including pain, tenderness, swelling in the calf and thigh, and redness in the involved extremity. Take serial leg measurements of the thigh and leg circumferences. In some clients there is a palpable, tender venous cord that can be felt in the popliteal fossa. Do not rely on Homans' sign. Thrombosis with clot formation is usually first detected as swelling of the involved leg and then as pain. Leg measurement discrepancies >2 cm warrant further investigation. Homans' sign is not reliable (Herzog, 1992; Launius, Graham, 1998). Unfortunately, symptoms of already-developed DVT will not be found in 25% to 50% of clients' exams, even though the thrombus is present (Eftychiou, 1996; Launius, Graham, 1998).
·         Note results of D-Dimer Test. High levels of D-Dimer, a febrin degradation fragment, is found in deep vein thrombosis, pulmonary embolism, and disseminated intravascular coagulation (Pagana, Pagana, 2001).
·         If DVT is present, observe for symptoms of a pulmonary embolism, especially if there is history of trauma. Based on data from 16 studies, fatal pulmonary embolisms have been reported in one third of trauma clients (Agency for Healthcare Research and Quality, 2000).
Geriatric
·         Change positions slowly when getting client out of bed. The elderly commonly have postural hypotension resulting from age-related losses of cardiovascular reflexes (Matteson, McConnell, Linton, 1997).
·         Recognize that if elderly develop a pulmonary embolus, the symptoms often mimic those of heart failure or pneumonia (Hyers, 1999).
Home Care Interventions
·         Differentiate between arterial and venous insufficiency. Accurate diagnostic information clarifies clinical assessment and allows for more effective care.
·         If arterial disease is present and client smokes, aggressively encourage smoking cessation. See Health-seeking behaviors.
·         Examine feet carefully at frequent intervals for changes and new ulcerations. Lower Extremity Amputation Prevention Program (LEAP) documentation forms are available at www.bphc.hrsa.gov/leap/ (Feldman, 1998).
·         Assess client nutritional status, paying special attention to obesity, hyperlipidemia, and malnutrition. Refer to a dietitian if appropriate. Malnutrition contributes to anemia, which further compounds the lack of oxygenation to tissues. Obese patients encounter poor circulation in adipose tissue, which can create increased hypoxia in tissue (Rolstad, 1990).
·         Monitor for development of gangrene, venous ulceration, and symptoms of cellulitis (redness, pain, and increased swelling in an extremity). Cellulitis often accompanies peripheral vascular disease and is related to poor tissue perfusion (Marrelli, 1994).
Client/Family Teaching
·         Explain importance of good foot care. Teach client/family to wash and inspect feet daily. Recommend that diabetic client wear padded socks, special insoles, and jogging shoes.
·         Teach diabetic client that he or she should have a comprehensive foot examination at least annually, including assessment of sensation with the Semmes-Weinstein monofilaments. If good sensation is not present, refer to a footwear professional for fitting of therapeutic shoes and inserts, the cost of which is covered by Medicare. Semmes-Weinstein monofilaments are effectively diagnostic of impaired sensation, and early diagnosis enables the nurse to take protective measures to prevent unnecessary amputations (Winslow, Jacobsen, 1999). Cushioned footwear can decrease pressure on feet, decrease callus formation, and help save the feet (George, 1993; Feldman, 1998).
·         For arterial disease, stress the importance of not smoking, following a weight loss program (if client is obese), carefully controlling diabetic condition, controlling hyperlipidemia and hypertension, and reducing stress. All of these risk factors for atherosclerosis can be modified (Bright, Georgi, 1992).
·         Teach client to avoid exposure to cold, to limit exposure to brief periods if going out in cold weather, and to wear warm clothing.
·         For venous disease, teach the importance of wearing support hose as ordered, elevating legs at intervals, and watching for skin breakdown on legs.
·         Teach client to recognize the signs and symptoms that need to be reported to a physician (e.g., change in skin temperature, color, sensation, or presence of a new lesion on the foot).
·         NOTE: If client is receiving anticoagulant therapy, see Ineffective Protection.

Tidak ada komentar: