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NursingCrib.com Nursing Care Plan Ineffective Tissue Perfusion

NursingCrib.com Nursing Care Plan Ineffective Tissue Perfusion

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Published by deric
A free sample nursing care plan (ncp) for Ineffective tissue perfusion related to vasoconstriction of blood vessels.
A free sample nursing care plan (ncp) for Ineffective tissue perfusion related to vasoconstriction of blood vessels.

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Published by: deric on Feb 12, 2009
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05/10/2014

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Assessment

Cues

Nursing Dx
> Ineffective tissue perfusion related to vasoconstriction of blood vessels.

Inference
> Increased cardiac output that injures the endothelial cells of the arteries and the action of prostaglandins. Vasoconstriction occurs and blood pressure increases.

Planning
After 4 hours of nursing intervention the pt blood pressure will decrease from 160/ 100mmHg to 120/80mmHg.

Nursing Intervention
> Monitored blood pressure every 4hours. > Instructed to have enough rest on semi fowlers position. > Instructed to eat low fat and low salt diet.

Rationale
> To know the base line of BP

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

> Sodium tends to be excreted at a faster rate. > To reduce edema that may activate renin angiotensinaldosterone system. > To control the BP and to avoid other complications.

> Administered anti- hypertensive drug as ordered.

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