ASSESSMENT .

NURSING DIAGNOSIS Ineffective tissue perfusion r/t decreased cardiac output

INFERENCE decreased cardiac output decreased preload and stroke volume decreased blood pumped out from the blood Decrease in stroke volume Decrease perfusion throughout the body.

GOAL SHORT-TERM: After 8 hours of nursing interventions, patient will be able to demonstrate behaviors to increase tissue perfusion, as evidence by: Decrease paleness for both conjunctiva and nail beds Decrease time in capillary refill Increase in strength of peripheral pulses Increase in warmness of the extremities

INTERVENTION

RATIONALE

EVALUATION SHORT-TERM: NOT MET After 8 hours of nursing interventions, pt. had not able to demonstrate behaviors to increase tissue perfusion, as evidenced by: Still pale for both conjunctiva and nail beds Still capillary refill time of more than 4 secs. weakness of peripheral pulses cold and clammy extremities

INDEPENDENT: Note current situation or presence of conditions that can affect perfusion to all body systems (Cardiac Arrhythmia) Determine history of conditions assoc. with thrombus/emboli (long periods of immobility) Note the effects in systemic circulation/perfusi on To identify client at higher risk for venous stasis, vessel wall injury and hypercoagulability Because it may restrict the circulation To determine adequacy of systemic circulation

OBJECTIVE: Pale conjunctiva and nail beds Capillary refill of greater than 4 seconds Weak peripheral pulses Cold clammy extremities Decreased ejection of fraction (2%) Atrial fibrillation (altered rhythm)

LONG-TERM: After 5 days of nursing interventions, patient will be able to demonstrate normal tissue perfusion, as evidence by: Normal redness of conjunctiva and nail beds Peripheral pulses stable and strong Normal temperature to both extremities Increasing the ejection fraction Normal heart rhythm

Note location of restrictive clothing or pressure dressing

Measure capillary refill

Inspect both lower and upper extremities for skin texture (lack of hair, dry and scaly)

That often accompany diminished peripheral circulation To promote peripheral circulation & promote general well being

Body turning every 2 hrs. and foot and ankle exercise

LONG-TERM: NOT MET After 5 days of nursing interventions, patient had not totally able to demonstrate normal tissue perfusion, as evidenced by: Still paled conjunctiva and nail bed Peripheral pulses were weak Cold and clammy temperature to both extremities Still in decrease ejection fraction In normal heart rhythm

Encourage us of antiembolic stockings

To avoid emboli

DEPENDENT Administer Clopidogrel, 75mg/tab, Once a day at 8 am To improve tissue perfusion or organ function

COLLABORATIVE: Collaborate in treatment of underlying conditions(HPN) Refer to wound care specialist if arterial/venous ulceration present Express the nedd for regular medical & laboratory follow up To maximize systemic circulation and organ perfusion To prevent further problems

Evaluate the disease progression and response to theraphies