Tissue Perfusion

Problem# 5 INEFFECTIVE PERIPHERAL TISSUE PERFUSION R/T EDEMA Assessment

Nursing

Scientific

diagnosis

Explanation

S- Ø O-

Planning

Intervention

Short term: the

patient

Rationale

1.Assess the site -

With

After

Peripheral

hypertension,

nursing

and

Tissue Perfusion

the cardiac

intervention, the

the severity of understanding of

r/t Edema

system can

patient

the condition.

become

able to verbalize 2.Monitor I & O

- To determine if enumerate

overwhelmed

understanding of

the

- bipedal edema

because the

condition

equal

- skin is tight and

heart is forced to

enumerate

output. Thereby pharmacologic

shiny and flaky

pump against

pharmacologic

determining

rising peripheral

and

there is still fluid

resistance. This

pharmacologic

reduces blood

regimen.

-

periorbital

edema

will

of of edema.

Outcome obtain Short term:

to

Ineffective

may manifest:

4°

Expected

be

and

non-

data The patient shall

determine have verbalized

Intake to

condition

and

is pharmacologic the and

non-

if regimen.

retention. Long Term:

supply to organs particularly the

baseline

3.Monitor Long Term:

kidneys.

patient’s signs

Vasospasm in

After 3 days of

the kidney

nurse-

patient 4.Encourage

- To obtain vital

patient’s baseline data

The patient shall have demonstrated

- To promote

increased

increases blood

interaction,

the ambulation

as venous return

perfusion as

flow resistance,

patient

will often

as

evidenced by

leading to a

demonstrate

decreased

increased

possible.

edema.

glomerular

perfusion

as 5.Instruct patient

filtration. Thus

evidenced

by to elevate legs

sodium

absence

of when sitting.

reabsorption and

edema.

fluid retention takes place. Due to an increased permeability, fluid shifting occurs from intravascular to interstitial spaces causing edema.

absence of -to promote venous return; reduce edema

6.Instruct a low - To reduce occurrence of salt low fat diet. fluid retention