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Ineffective tissue perfusion careplan

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llwallace llwallace (New) New

So im in my first semester of nursing school and careplans are just kicking my butt. Im pretty sure my teacher runs out of ink by the time she gets done with my papers. This week we have to make a careplan related to AIR! Soooooo my teacher said for me to do ineffective tissue perfusion. Im struggling with coming up with interventions. My teacher has said that most of my interventions are to basic.... any help with stepping it up this week would be appreciated or im pretty sure she is going to literally eat me

thanks

Do you have a care plan book to refer to? LIFESAVER!

Try these:

Ineffective Tissue Perfusion: Peripheral

related to interruped venous flow secondary to prolonged immobility

Then think about what types of things you can do as a nurse to improve the patient's circulation so the peripheral tissues are better perfused.

Interventions like...having the patient perform ROM exercises...or you can do passive ROM if the patient is unable to do them him/herself.

Deep breathing to increase the oxygen delivered to the alveoli for diffusion.

Just think about what is going to get more oxygen to the blood, more blood out to the tissues, and encourage that perfusion. Then make it all SMART -- specific, measurable, attainable, realistic and timed.

my patients diagnoses are:

dysphagia

hypothyroidism

hypertension

depressive disorder

cva

chf

anxiety

meds: amlodipine,furosemide, levothyroxine, calcium carbonate, venlafaxine

my teacher has stressed adding the meds into our interventions. im just not good at wording things into so called "nursing words" i guess

Daytonite, BSN, RN

Specializes in med/surg, telemetry, IV therapy, mgmt. Has 40 years experience.

first, understand that a care plan is a big list of what you have determined to be the patient's nursing problems and the things (interventions) you are going to do for those problems. the entire care plan is based on your initial assessment of the patient. if your assessment information sucks, the rest of the care plan including your interventions is going to suck. it is important that you follow the nursing process in construction your plan of care because it will not only help you keep organized, but give you your critical, rational thinking.

it is interesting that your instructor wants you to use ineffective tissue perfusion, but you need to understand that each nursing diagnosis has a definition and signs and symptoms that the patient must have in order for you to say they have that problem. your instructor must have decided from what they saw in the data that some of those signs and symptoms were present. this is important because your nursing interventions are aimed at and target those symptoms. that is how interventions become customized and specific to the patient's needs rather than "too basic".

step #1 assessment. a nursing assessment consists of doing the following:

  • a health history (review of systems) - all you've told us is that the patient has dysphagia, hypothyroidism, hypertension, depressive disorder, had a cva, chf and anxiety.
  • performing a physical exam - no physical exam information is provided. what were the lung sounds like? the blood pressure? pulses? was there any edema? skin discoloration? what body system is this tissue perfusion problem occurring in (brain, lung, heart, gi, extremities) and what are the symptoms the patient has of it? you must have that information before proceeding to diagnosing any problem.
  • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - no information provided.
  • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - medical diseases and conditions need to be looked up. the pathophysiologies will often explain and be needed for the "related to" parts of your nursing diagnostic statements (why the problem is happening).
  • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - you listed amlodipine, furosemide, levothyroxine, calcium carbonate and venlafaxine. these drugs are being given to control the symptoms of hypertension, chf, hypothyroidism and depression. those same symptoms of these diseases are what you would be using to diagnose nursing problems and that is how the administration of some of these medications will find their way into your nursing interventions.

step #2 - determining the nursing problem and naming it (nursing diagnosis). from all that information you collected above you will have some normal and some abnormal data. for the purpose of diagnosis we are interested in what is abnormal. for example, a cough is abnormal and becomes, for us, a symptom of a problem. what the problem is will depend on other information we have to put together with it. i am really at a disadvantage here because no physical exam information was provided and a body system needs to be specified with ineffective tissue perfusion. i cannot tell what body system is involved here from the information you have provided. without that information i really can't go any further with the next step which is the development of goals and nursing interventions.

step #3 - develop goals and nursing interventions. these are always based on and target the signs and symptoms of the nursing problem.