ASSESSMENT DIGNOSIS PLANNING
OBJECTIVE: Risk for altered Short term
peripheral tissue
(+)swollen lymph perfusion related to After 8hrs of nursing
nodes inflammation of blood intervention the patient will
ESR results of : vessels. show increase perfusion as
39mm/hr individually appropriate
vital sign’s within clients
normal range.
Long term
After 24 hrs of nursing
intervention the patient will
demonstrate behaviour
changes to improve
circulation.
INTERVENTION RATIONALE EVALUATION
INDEPENDENT:
Short term
Monitor quality of all Assessment is needed
pulses for ongoing After 8hrs of nursing
comparisons; loss of intervention the patient will
peripheral pulses must able to show increased
be reported or treated perfusion as individually
immediately appropriate vital sign’s
within clients normal range.
Identify changes To assess causative Long term
related to systematic contributing factors
and peripheral After 24 hrs of nursing
alterations in intervention the patient will
circulation. able to demonstrated
behaviour changes to
Perform assistive range To maximize tissue improve circulation.
of motion exercise perfusion
Provide preoperative
teaching appropriate To promote wellness
for the situation.
Use pulse oximetry to Pulse oximetry is a
monitor oxygen useful tool to detect
saturation and pulse changes in
rate. oxygenation.
Dependent:
Administer oxygen as This saturates
needed circulating
Collaborative :

Review laboratory test to have baseline.