Hi! This is Janine, Jackie's (lccougar02) twin. I need help with my care plan.

Janinern84 · Oct 9, 2005

My turn to see if i suck like Jackie does lol jk Jack.

I finished the care plan, just was wondering if someone can proofread. Also, I need a deadline...I'm never good at that part. Please help :) :uhoh21:

Care plan

Problem statement: Ineffective Tissue Perfusion (peripheral)

related to interrupted venous flow resulting from statis dermatitis.

Manifested by:

a.errythematous, scaly, and roughness to integument bilaterally to lower legs.

b.+1 pulses posterior tibialis and doralis pedis pulses.

c.Decreased capillary refill to bilateral lower extremities.

Desired goal:

1.The client will demonstrates adequate tissue perfusion.

As evidenced by:

a.The client will have palpable peripheral pulses.

b.The client will have warm and dry skin.

c.The client will have increase capillary refill

Deadline:

Nursing orders:

1.Check dorsalis pedis and posterior tibial pulses bilaterally q shift. Use Doppler is unable to find and notify doctor if unable to find.

2.Elevate edematous legs and ensure no pressure under knee q shift.

3.Observe for signs of deep vein thrombosis, including pain, tenderness, swelling in the calf and thigh, and redness in the involved extremity q8h.

Rationales:

1. Diminished or absent peripheral pulses indicate arterial insufficiency (Harris, Brown-Etris, Troyer-Caudle, 1996).

2. Elevation increases venous return and helps decrease edema. Pressure under the knee decreases venous circulation. Client will obey this once put in the position via the wheelchair.

3. 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).

Any help is well appreciated!!!

Thanks!!

~Janine