Gaffud, Lloyd Adrian R.

BSN – 309

Nursing Diagnosis Rank Justification

Ineffective tissue 1st The actual gas exchange takes place in very small
perfusion related to blood vessels called capillaries, and this healthy
diabetic coma transfer of gases is called tissue perfusion. All of the
cells in the body require oxygen and nutrients for
cellular respiration, and they need a way to get rid of
carbon dioxide; as you can see, blood is critically
important to this process. The body can’t function
without oxygen.
According to Maslow’s hierarchy of needs these are
biological requirements for Human survival If these
needs are not satisfied the human body cannot
function optimally. Maslow considered
physiological needs the most important as all the
other needs become secondary until these needs are
met.

Reference:
McLeod, S. (2007). Maslow's hierarchy of
needs. Simply psychology, 1, 1-8.
Impaired gas exhange 2nd
Decreased cardiac 3rd
output
Self-care deficit 4th
Imbalanced nutrition: 5th
Less than body
requirement
 Cues Nursing Analysis Goals and Interventions Rationale Evaluation
Diagnosis Objectives
Subjective: Ineffective Several studies Goal: Independent: Independent: Goal:
tissue have shown After 3 days of  Note current Affecting After 3 days of
Objective: perfusion as impaired nursing situation or systemic nursing
- Diagnosed related to coronary flow intervention circulation/perfusi intervention the
presence of
reserve in
with diabetic the client will conditions on client was able
diabetic
Diabetes comatose be able to to maintains
individuals in
mellitus the absence of maintains  Identify Can place the maximum
- Patient is coronary artery maximum presence of client at greater tissue perfusion
in a stenosis. In tissue high-risk risks for to vital organs,
diabetic people with type perfusion to factors or developing as evidenced by
coma 2 diabetes, vital organs, as condition peripheral warm and dry
- Underwent coronary flow evidenced by vascular disease skin, present
dialysis reserve is warm and dry with associated and strong
twice inversely related skin, present complication peripheral
to hemoglobin and strong pulses, vitals
A1C and fasting  Note location May restrict
peripheral within patient’s
plasma glucose of restrictive
pulses, vitals circulation to the normal range,
levels, which
within clothing, limbs balanced I&O, ,
suggests that
patient’s pressure normal ABGs.
chronic
hyperglycemia normal range, dressing,
is a key factor. balanced circular Was the
The impairment I&O, , normal wraps, cast, or intervention
in coronary flow ABGs. traction appropriate,
reserve is more acceptable, and
severe in Objective:  Ascertain Client that has no efficient to the
diabetic patients impact of
After 3 hours range of motion patient
with retinopathy of nursing condition on may restrict condition?
than in those intervention functioning ambulation or
without and is the patient will and lifestyle may develop skin Met:
worse in those be able to: ulceration and Partially Met:
with advanced
healing problems Not Met:
rather than mild
Exhibit no that seriously
retinopathy. An
inverse relation further impact quality of Objective:
between worsening/repe life After 3 hours of
hyperemic tition of nursing
myocardial deficits. Dependent: Dependent: intervention the
blood flow and  Assess skin Help in patient was
fasting insulin Exhibits color, determining able to:
level has also growing temperature, location and type
been found tolerance to moisture, and of perfusion Exhibit no
among healthy, activity problem further
whether
nonobese
changes are worsening/repe
individuals,
widespread or tition of
which suggests
that even mild localized’ deficits.
insulin Helps
resistance is  Compare skin differentiate type Was the
associated with temperature of problem intervention
impaired and color with appropriate,
coronary flow other limb acceptable, and
reserve The when efficient to the
decreased patient
assessing
myocardial condition?
extremity
perfusion in
circulating
diabetes is due
Met:
primarily to
reduced To determine Partially Met:
maximal  Measure adequacy of Not Met:
myocardial capillary refill systemic
blood flow. circulation
Exhibits
Reference: growing
Protein-energy
Levy, B. I., tolerance to
 Note client’s malnutrition and
Schiffrin, E. activity
nutritional weight loss make
L., Mourad, J.
and fluid ischemic tissues
J., Agostini,
status more prone to Was the
D., Vicaut, E.,
breakdown . intervention
Safar, M. E., &
dehydration appropriate,
Struijker-
reduces blood acceptable, and
Boudier, H. A.
volume and efficient to the
(2008).
compromises patient
Impaired tissue
peripheral condition?
perfusion: a
circulation
pathology
common to Met:
hypertension, Partially Met:
To improve tissue Not Met:
obesity, and
 Administer perfusion or
diabetes
fluids, organ function
mellitus. Circu
electrolytes,
lation, 118(9),
nutrients, and
968-976.
oxygen as
indicated
Collaborative:
Collaborative: Promotes
 Identify independence,
necessary enhances self-
 changes in concept regarding
lifestyle and ability to deal
assist client with change and
to incorporate manage own
disease needs
management
into activities
of daily
living
Smoking
 Provide contributes to
education development and
about progression of
relationship peripheral
between vascular disease
smoking and and is associated
peripheral with higher rate
vascular of amputation in
circulation as presence of
indicated Buerger’s disease

To evaluate
 Emphasize disease
need for progression and
response to
regular therapies
medical and
laboratory
follow-up
Client may be on
 Review various drugs for
medication treatment of the
regimen and particular
vascular disorder.
possible
Many of these
harmful side medications have
effects with harmful side
client effect and require
client teaching
and ongoing
medical
monitoring

Reference:
Doenges, J.,
Moorhouse, M.,
Murr, A. (2016).
Nurse’s Pocket
Guide 14th
edition. pp 878-
884