Ineffective Tissue Perfusion

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    Okay, so here I am again. I think this time I have collected more data, but not as much as I would have liked bc I ran out of time. I have an 82 yr old female who had a syncopial episode and fainted. She fell and had a fracture to her left femoral neck. She has had hip surgery in the past, so this was nothing new for her. She has a history of chronic kidney disease stage II, HTN, hypothyroidism, anemia, osteoarthritis, and syncope/dizziness. Her lab values for HGB: 10.5(they are low), HCT: 30.6(low also), RBC: 3.9(Low as well). Okay, so for a nursing diagnosis I have....Ineffective tissue perfusion r/t decreased hemoglobin concentration in the blood aeb weak peripheral pulses. Is this good? Am I on the right track this time? And how in a 4 hour shift am I supposed to have 10 interventions? Is that possible? Here is what I have so far and I just do not feel like it is good enough. Any feed back is appreciated. I also have to come up with 5 goals, I'm working on it, but only have one.
    Goals:When shift is over the patient will be able to verbalize understanding of condition and therapy regimen.
    Interventions:
    1-Establish rapport with patient. Trust will help the patient open up and tell me more about whatis going on and what happened when she had her accident.

    2-Perform handhygiene to prevent the spread of bacteria to patients wounds.(My instructor suggests we must always have this on as an intervention and that the first intervention should be some type of assessment)

    3-Monitor vital signsto have baseline data. Report any abnormalities.

    4-Perform full body assessment on patient and not any abnormalities.

    5-Encourage quiet and restful atmosphere.

    6-Encourageambulation to promote venous return.

    7-Discourage sittingwith legs crossed or standing for long periods of time and wearing constrictiveclothing.

    8-Encourage patientto each foods rich in iron to help with anemia.

    9-Administermedications as ordered.

    10-Scheduleactivities for periods when patient has the most energy.

    Being sleep deprived is really not helping me, but am I on the right track? Is this good enough?
    Last edit by Esme12 on Apr 25, '13 : Reason: Formatting

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  2. 4 Comments...

  3. 0
    Never mind...disreguard this I have it figured out I think and I don't know how to delete a post!
  4. 0
    You can report your original post and ask to have it deleted Grats on figuring it out!
  5. 0
    Hemoglobin doesn't affect peripheral pulses.

    A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."


    "Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."


    To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!
    If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:
    1, health promotion (teaching, immunization....)
    2, nutrition (ingestion, metabolism, hydration....)
    3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)
    4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)
    5, perception and cognition (attention, orientation, cognition, communication...)
    6, self-perception (hopelessness, loneliness, self-esteem, body image...)
    7, role (family relationships, parenting, social interaction...)
    8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)
    9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)
    10, life principles (hope, spiritual, decisional conflict, nonadherence...)
    11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)
    12, comfort (physical, environmental, social...)
    13, growth and development (disproportionate, delayed...)


    Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.
  6. 0
    Quote from llee316
    Okay, so here I am again. I think this time I have collected more data, but not as much as I would have liked bc I ran out of time. I have an 82 yr old female who had a syncopial episode and fainted. She fell and had a fracture to her left femoral neck. She has had hip surgery in the past, so this was nothing new for her. She has a history of chronic kidney disease stage II, HTN, hypothyroidism, anemia, osteoarthritis, and syncope/dizziness. Her lab values for HGB: 10.5(they are low), HCT: 30.6(low also), RBC: 3.9(Low as well). Okay, so for a nursing diagnosis I have....Ineffective tissue perfusion r/t decreased hemoglobin concentration in the blood aeb weak peripheral pulses. Is this good? Am I on the right track this time? And how in a 4 hour shift am I supposed to have 10 interventions? Is that possible? Here is what I have so far and I just do not feel like it is good enough. Any feed back is appreciated. I also have to come up with 5 goals, I'm working on it, but only have one.
    Goals:When shift is over the patient will be able to verbalize understanding of condition and therapy regimen.
    Interventions:
    1-Establish rapport with patient. Trust will help the patient open up and tell me more about whatis going on and what happened when she had her accident.

    2-Perform handhygiene to prevent the spread of bacteria to patients wounds.(My instructor suggests we must always have this on as an intervention and that the first intervention should be some type of assessment)

    3-Monitor vital signsto have baseline data. Report any abnormalities.

    4-Perform full body assessment on patient and not any abnormalities.

    5-Encourage quiet and restful atmosphere.

    6-Encourageambulation to promote venous return.

    7-Discourage sittingwith legs crossed or standing for long periods of time and wearing constrictiveclothing.

    8-Encourage patientto each foods rich in iron to help with anemia.

    9-Administermedications as ordered.

    10-Scheduleactivities for periods when patient has the most energy.

    Being sleep deprived is really not helping me, but am I on the right track? Is this good enough?
    You are putting the cart in front of the horse.....you are picking the diagnosis you like and retrofitting the patient into it. Many students do this....this is not how a care plan is done.

    The care plan is all about the assessment OF THE PATIENT. Your patient has what is essentially a broken hi........ I would think she has pain. What else does she complain about...What else does she NEED? What symptoms does she have? What complications could this diagnosis/condition cause this patient? How does she tolerate activity? Does she need assistance with her ADL's? With her kidney issues how is her fluid balance? What can be causing her syncope and dizziness? What meds is she on? What labs are affected by chronic kidney disease and how would they affect your patient?

    I need you to explain to me how a low hemoglobin (and on a patient that has CHRONIC anemia with kidney disease) decreases peripheral pulses in the absence or an acute volume loss...hemorrhage. It might cause ineffective tissue perfusion due to lower oxygen being carried to the tissues due to Impaired transport of oxygen from a Decreased hemoglobin concentration in blood...but that has no impact on the pulses.

    What care plan book do you use? I use Ackley and Gulanick.


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