Nursingcrib.com Nursing Care Plan Ineffective Tissue Perfusion
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Assessment Cues
(Subjective) > “Nahihilo ako” as verbalized
(Objective) PR = 85 bpm RR = 30 bpm 160/100mmHg
Nursing Dx
Inference
Planning
> Ineffective tissue perfusion related to vasoconstriction of blood vessels.
> Increased cardiac output that injures the endothelial cells of the arteries and the action of prostaglandins. Vasoconstriction occurs and blood pressure increases.
After 4 hours of nursing intervention the pt blood pressure will decrease from 160/ 100mmHg to 120/80mmHg.
Nursing Intervention
Rationale
> Monitored blood pressure every 4hours.
> To know the base line of BP
> Instructed to have enough rest on semi fowlers position.
> Sodium tends to be excreted at a faster rate.
> Instructed to eat low fat and low salt diet.
> Administered anti- hypertensive drug as ordered.
> To reduce edema that may activate renin angiotensinaldosterone system. > To control the BP and to avoid other complications.
Evaluation > After 4 hours of nursing intervention the patient’s blood pressure was decreased from 160/100mmHg to 140/90mmHg.
(Subjective) > “Nahihilo ako” as verbalized
(Objective) PR = 85 bpm RR = 30 bpm 160/100mmHg
Nursing Dx
Inference
Planning
> Ineffective tissue perfusion related to vasoconstriction of blood vessels.
> Increased cardiac output that injures the endothelial cells of the arteries and the action of prostaglandins. Vasoconstriction occurs and blood pressure increases.
After 4 hours of nursing intervention the pt blood pressure will decrease from 160/ 100mmHg to 120/80mmHg.
Nursing Intervention
Rationale
> Monitored blood pressure every 4hours.
> To know the base line of BP
> Instructed to have enough rest on semi fowlers position.
> Sodium tends to be excreted at a faster rate.
> Instructed to eat low fat and low salt diet.
> Administered anti- hypertensive drug as ordered.
> To reduce edema that may activate renin angiotensinaldosterone system. > To control the BP and to avoid other complications.
Evaluation > After 4 hours of nursing intervention the patient’s blood pressure was decreased from 160/100mmHg to 140/90mmHg.
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