Nursing Diagnosis Goal or Outcome Nursing Interventions Rationale Evaluation

Ineffective Tissue Within 30 minutes Independent Interventions: Goal met. After 30

Perfusion related to the the client will be 1. Assess the presence, minutes of nursing
decreased able to demonstrate location, and degree  To evaluate degree of interventions client was
impairment.
coagulability of blood increased perfusion of swelling or edema able to maintain
as evidenced by blood as individually foundation. optimal peripheral
clotting. appropriate tissue perfusion in the
(peripheral pulses affected extremity, as
SUBJECTIVE DATA: present and strong, 2. Provide warm, moist  Heat promotes evidenced by strong
comfort and reduces
 Paresthesia absence of edema, heat to the affected palpable pulses,
 Pain scale of 5 out inflammation.
adequate capillary site. reduction in and/or
of 10 refill, free of pain absence of pain, warm,
 Discomfort and discomfort.) 3. Encourage the patient and dry extremities,
 Hydration prevents
OBJECTIVE DATA: to maintain adequate absence of edema, and
an increased viscosity
 Presence of edema
hydration. of blood, which adequate capillary refill.
 Decreased of
contributes to venous
peripheral pulses
stasis and clotting.

Dependent Interventions:
1) Administer analgesics  Analgesics relieve
as prescribed. pain and promote
comfort.

2) Administer anticoagul  Treatment with

ants as anticoagulant is used
primarily to prevent
(heparin/warfarin
the formation of new
[Coumadin]) as
clots by decreasing
prescribed. the normal activity of
the clotting
mechanism.

Collaborative Intervention:
I. Collaborate with the
 To maximize
attending physician in
systematic circulation
treatment of
and organ perfusion.
underlying conditions
such as diabetes,
hypertension, and etc.

II. Refer to wound care  Provide optimal

specialist if arterial or moisture for healing
venous ulcerations prevention of
infection, and further
are present.
injury.

III. Refer to dietitian for  To offer the patient a

well-balanced meals. proper meal plan.