DEFINING CHARACTERISTICS

Nursing Diagnosis:
Ineffective tissue perfusion: Fetal cardiac and Cerebral related to altered placental blood
flow caused by vasospasm and thrombosis

S: “nang-hupong aku mga tiil ug kamot, unya taas pirmi aku BP,” as verbalized.
O: Increase in blood pressure, pulse, and respirations noted
Dizziness, light-headedness
Edema noted
Restlessness; confusion

EXPECTED OUTCOME CRITERIA

Short term goal:

After 8 hours of nursing intervention patient will be able to verbalize understanding of
condition and identify ways to achieve effective tissue perfusion.

Long term goal:

After 6 days of nursing care, patient will be able to maintain optimal tissue perfusion to
vital organs, as evidenced by strong peripheral pulses, alert LOC, and absence of chest pain.

INTERVENTION AND RATIONALE

Independent:

I: Encourage left side-lying position

R: Promote fetal circulation
S: Lippincott. MNP. p.1271

I: Monitor vital signs q hourly

R: To detect changes in circulation
S: Lippincott. MNP. p. 1271

I: Obtain fetal heartbeat q hourly

R: to monitor fetal status
S: Lippincott. MNP. p. 1271

I: Do passive ROM exercises to unaffected extremity every 2 to 4 hr

R: to prevent venous stasis
S: Gulanick, et. al. NCP. p. 70

I: Maintain optimal cardiac output

R: To ensure adequate perfusion of vital organs
S: Gulanick, et. al. NCP. p. 70
I: Position properly
R: to promote optimal lung ventilation and perfusion
S: Gulanick, et. al. NCP. p. 70

I: Elevate head of bed 30-45 degrees

R: to promote venous outflow from brain and help reduce pressure
S: Gulanick, et. al. NCP. p. 70

Dependent:

I: Administer oxygen as indicated

R: To provide enough oxygen supply to fetus
S: Lippincott. MNP. p.1272

I: Assist with diagnostic testing as indicated

R: Doppler flow studies, angiograms, etc. may be required for accurate diagnosis.
S: Gulanick, et. al. NCP. p. 70

I: Administer medications such as antihypertensive as indicated

R: Antihypertensive drugs are prescribed to decrease blood pressure level

THEORETCIAL BASIS

Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level. (Tissue
perfusion problems can exist without decreased cardiac output; however, there may be a
relationship between cardiac output and tissue perfusion)

Reduced arterial blood flow causes decreased nutrition and oxygenation at the cellular level.
Management is directed at removing vasoconstricting factor(s), improving peripheral blood flow,
and reducing metabolic demands on the body. Decreased tissue perfusion can be transient with
few or minimal consequences to the health of the patient. If the decreased perfusion is acute and
protracted, it can have devastating effects on the patient. Diminished tissue perfusion, which is
chronic in nature, invariably results in tissue or organ damage or death. This care plan focuses on
problems in hospitalized patients.

BIBLIOGRAPHY
1 Doenges, et. al. (2002). Nursing Care Plans. 6th Ed. F.A. Davis Company.
2. Doenges, et. al. (2002). Nurses’ Pocket Guide. 8th Ed. F.A. Davis Company.
3. Gulanick, et. al.(1994). Nursing Care Plans. 3rd Ed. Mosby-Yearbook, Inc.
4. Nettina, S. (2006). Lippincott Manual of Nursing Practice. 8th Ed. Lippincott Williams and
Wilkins.
5. Pillitteri, A. (2003). Maternal and Child Health Nursing. 4th Ed. Lippincott Williams and
Wilkins