nursing student

[kb9299]

I feel silly about asking for help but I need some nursing interventions on ineffective tissue perfusion as evidenced by edema. Can anyone help me. Also some diagnosis and interventions on erythroblastosis fetalis. I'm in the LVN program and its only so much we can do without RN's. So it has to be reasonable. PLEASE HELP!!!!!

[NaomieRN]

http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfmhttp://www1.us.elsevierhealth.com/Evolve/Ackley/NDH6e/Constructor/P-Z.htmlYou can use this site to help you with careplans. Good luck to you.

[Daytonite, BSN, RN]

for your first diagnosis (ineffective tissue perfusion), the symptom (defining characteristic) that you are addressing is "edema". by the way, where was this edema: leg, arm or all over the body? what is the etiology (cause) if the edema? this will have an effect on the nursing interventions you will use. the fact that your patient's symptom to support the ineffective tissue perfusion is "edema" means that your nursing interventions must address this edema. and, by the way, ineffective tissue perfusion must be specified as being renal, cerebral, cardiopulmonary, gastrointestinal or peripheral. edema is only a symptom of peripheral ineffective tissue perfusion. so, if this is not the case with your patient, then you have diagnosed the patient incorrectly.

you should look at the index of your nursing textbook for listings of "edema" and "swelling" to find interventions. some things i can think of are:

• assess/monitor/evaluate/observe
  • note onset, location and describe if the edema
    
  • note any pitting
    
  • look for any external injury at the place of edema
    
  • assess the patient for shortness of breath or pain
    
  • compare both arms and legs for symmetrical edema daily
    
  • observe for any bruising or cyanosis
    
  • observe the dependent areas of a bedridden patient for dependent edema
    
  • assess for pulses in the extremities and note any coolness in the hands or feet of edematous limbs
    
  • assess heart and lung sounds
    
  • monitor intake and output every shift
    
  • weigh the patient daily
    
  • perform a neuro assessment of the limbs each shift
    
  • palpate the lower extremities for warmth, tenderness or cords

  [*]care/perform/provide/assist

  • position the patient with affected limbs above the heart level to promote drainage
    
  • prevent breakdown of the edematous skin by keeping linens smooth and unwrinkled
    
  • restrict fluids and sodium as ordered if these are at the basis of the edema
    
  • administer diuretics as prescribed
    
  • apply antiembolism stockings or bandages as prescribed
    
  • encourage patient not to scratch at any edematous skin that is itchy
    
  • perform passive rom on edematous arms and legs to get circulation moving
    
  • report dyspnea to the rn and prepare to elevate the head of the bed and administer oxygen

  [*]teach/educate/instruct/supervise

  • teach the patient the signs and symptoms of edema that they should report to the doctor
    
  • teach patient how to do leg and arm exercises
    
  • teach the patient which foods or fluids they should avoid

  [*]manage/refer/contact/notify

  • review the drugs the patient is taking and observe for expected effects and side effects
    
  • monitor electrolytes and report abnormalities to the doctor

i cannot help you with the erythroblastosis fetalis part of your question. a care plan is based upon a patient's signs and symptoms not their medical diagnosis. you determine their signs and symptoms by doing a physical assessment, interview and reviewing the information that is in their medical record. provide the non-normal data for me and i can help you determine what this patient's nursing diagnoses might be. any nursing diagnosis you assign to a patient is always based upon the symptoms they have.