ADVENTIST MEDICAL CENTER COLLEGE

Brgy. San Miguel, Iligan City

SCHOOL OF NURSING

NURSING CARE PLAN

Client Name:
Age: 9 years old

Nursing diagnosis: Ineffective tissue perfusion related to hypovolemic shock as evidenced by dyspnea, hemoptysis, edema,
hypotension, lethargy and low platelet count.
Assessment Planning Nursing Interventions Rationale Evaluation
Data based on (Desired or
PEROS and Expected
GORDON’S Outcomes)
Subjective Data: STO: Independent: Independent: STO:
After 8-12 hours of 1. Assess vital signs 1.Closely monitor blood After 8-12 hours of nursing
When asked if she’s nursing 2. Assess for sudden pressure, heart rate, interventions, client was
tired, the Px said, interventions, client changes. respirations, and changes in able to:
“Yes”. will be able to: 3. Take a complete cardiac rhythms. Use this - Patient will maintain
Additionally - Patient will health history. data to compare to baseline cardiopulmonary perfusion
acccording to the maintain 4. Be aware of signs of information to identify as evidenced by normal
patients mother cardiopulmonary infection. changes in condition. sinus heart rhythm, heart
“kalit ra nga gikan perfusion as 5. Review lab work and rate within normal limits,
siyag dula tapos ga evidenced by normal test results. 2. Note the presence of and no complaints
tungok ra siya na sinus heart rhythm, 6. Monitor hemoglobin sudden chest pain, of shortness of breath
kiat man unta kaayo heart rate within levels. diaphoresis, respiratory - Patient will demonstrate
na siya luya kaayo normal limits, and 7. Assess capillary refill distress, and hemoptysis appropriate lifestyle
siya tapos pagka tulo no complaints 8. Note clients which could signal a modifications to support
ka adlaw mao nato of shortness of nutritional and fluid pulmonary embolus. adequate tissue perfusion
lipong siya tapos ga breath status
suka” - Patient will Collaborative or 3. Assess for acute and
demonstrate Interdisciplinary chronic conditions that
Objective Data: appropriate lifestyle Care: affect perfusion: history of LTO:
- Signs of bleeding modifications to 1. Administer blood clots, myocardial After 2 days of nursing
DAY 1 – Blood- support adequate medications to improve infarction, congestive heart interventions, client was
streaked sputum tissue perfusion blood flow failure, diabetes, vascular able to:
-with O2 support -Tranexamic Acid diseases, organ failure. - Patient will maintain
(Hemostan) Consider that certain adequate peripheral
inhalation (1Lpm-
250mg Q8H IV conditions can affect the perfusion as evidenced by
3Lpm) LTO: - Dobutamine drip perfusion of multiple body strong pedal pulses, warm
RR- 16 bpm - 37 After 2 days of (double strength) systems. skin temperature, and
bpm nursing 300mg/250 ml @ 5.6 4. If not quickly identified intact skin without edema
-Edematous upper interventions, client cc/hr and treated, sepsis can cause
extremities will be able to: - Norepinephrine 2A poor perfusion and organ
-Lethargic - Patient will amps + NSS to make failure evidenced by
-Low Platelet count maintain adequate 50 cc at 0.5 cc decreased urine output,
peripheral perfusion -Dopamine drip abrupt mental status change,
(19, 27, 35, 55)
as evidenced by 400mg/250mL D5LR at and mottled skin.
NOV.7 (7AM- strong pedal pulses, 8cc/hr 5. Arterial blood gases,
11PM): warm skin 2. Provide supplemental complete blood counts,
HR=112-188 temperature, and oxygen as indicated (O2 electrolytes, and CT scans or
BP=70/40-139/109 intact skin without inhalation @2-3LMP ultrasounds should be
edema via nasal cannula) reviewed for signs of new or
NOV. 8 (12AM- 3. Emphasize and worsening perfusion issues.
11PM): involve S/O(s)’ the need This information can also be
HR=89-175 for exercise as tolerated. referred to for comparison.
BP=70/40- 115/87 6. Hemoglobin is a red
blood cell component that
NOV. 9 = (12AM- carries oxygen through the
11PM): body. If hemoglobin is
HR=84-112 decreased, less oxygen will
BP=70/40- 104/62 be perfused through the
 body and tissues.

7. Capillary refill assesses

circulation and peripheral
perfusion. If capillary refill
time is sluggish, the client
may be hypovolemic and
lack blood volume to
support the circulatory
system with adequate
oxygenation.
8. Protein energy
malnutrition and weight loss
make ischemic tissues more
prone to breakdown,
dehydration reduces blood
volume and compromises
peripheral circulation.

Collaborative or
Interdisciplinary Care:
1. To improve blood flow
for chest pain, high blood
pressure.
2. To provide extra oxygen
to breathe in and needed for
the body to function.
3. To enhance circulation
and promote well being.

References: Ineffective Tissue Perfusion Nursing Diagnosis & Care Plan. (2023, January 14). Retrieved from
https://www.nursetogether.com/ineffective-tissue-perfusion-nursing-diagnosis-care-plan
 Doenges, M., Moorhouse, M., & Murr, A. (2022). In Nurse’s Pocket Guide, Diagnoses, Prioritized Interventions, and
Rationales, 16th ed. (pp. 616-621). Philadelphia: F.A. Davis Company.

Nursing diagnosis : Risk for Impaired skin integrity related to imobility and presence of petechial rash
Assessment Planning Nursing Interventions Rationale Evaluation
Data based on (Desired or
PEROS and Expected
GORDON’S Outcomes)
Subjective Data: STO: Independent: Independent: STO:
“Usahay ma’am naa After 8-12 hours of 1.Assess for rashes which 1. Hermans rash/sign After 8-12 hours of nursing
siya’y rashes nursing may be present on usually appears on the interventions, client was
mapansin namo interventions, client other areas of body. upper and lower able to:
magabii sukad atong will be able to: 2. Assess skin turgor, extremities about 1cm or - Identify underlying risk
na admit siya dayun - Identify underlying sensation, and circulation less in size. Although factors involved in skin
ushay iyang risk factors involved 3. Maintain skin hygiene typically located in integrity impairment. (
ipakatol” as in skin integrity using mild soap and extremities, unusual Hermans rash/sign usually
verbalized by the impairment. lukewarm water. Pat dry manifestation of rash may appears is commonly seen
mother. -Participate in skin gently and thoroughly. be generalized classic on patients with dengue)
Additionally the prevention measures 4. Remove wet and rash. Itchiness may be -Participate in prevention
mother verbalized. and treatment wrinkled bed sheets present at times. measures and treatment
“Nagsugod nag programs promptly. Keep bed clothes 1. Poor skin turgor, programs
hubag iyang kamot dry, use non irritating decreased sensations
atong miaging adlaw LTO: materials and keep bed free (nerve damage), and poor LTO:
tapos dili siya After 2 days of of wrinkles,and crumbs. circulation (lack of blood After 2 days of nursing
ganahan mulihok” nursing 5. Monitor ambulation flow assessed via interventions, client was
interventions, client status and bed mobility palpation of pulse sites as able to:
Objective Data: will be able to: 6. Consider incontinence well as observed by - maintain optimal skin
- Bruises noted on - maintain or self-care deficit purplish or ruddy integrity within the limits of
extraction sites optimal skin 7. Assess pitting edema discoloration of lower the disease, as evidenced by
- Presence of integrity within the 8. Elevate edematous legs) increase the risk of intact skin.
limits of the disease, extremities. tissue damage.
petechial rashes
as evidenced by 2. Skin hygiene needed to
-Bruises noted on intact skin. prevent secondary
extraction sites Collaborative or infection and avoid
- A patch of skin that Interdisciplinary Care: rubbing skin to prevent
feels warm, spongy 1. Administer medications. skin breakdown. Avoid
or hard. Furosemide (Lasix) 14mg harsh soaps that can dry
IV and cause skin breakdown
2. Provide or advice 3. To provide maximum
significant other to use relief from itchiness
DAY 1 = Nonpitting light clothing material that 4. Patients who cannot
edema on right hand is comfortable to the clien walk or cannot shift their
weight in a chair or bed
DAY 2 = Nonpitting are at a higher risk for
edema on both upper skin breakdown. Patients
extremities who may have adequate
mobility but are under the
use of restraints are also at
risk.
5. Patients who are unable
to ask for assistance to use
the bathroom or are
incontinent need frequent
monitoring to keep skin
dry and clean.
6. Severe edema can be
documented as pitting on
a scale of 1+-4+ which is
assessed by the depth of
indentation in the skin
without rebound when
applying pressure.
7. Elevate edematous
extremities above the
level of the heart several
times per day to ease
swelling.

Collaborative or
Interdisciplinary Care:
1. Diuretics are provided
to patients with edema
and excess fluid
accumulation to aid in
fluid elimination by
increasing urine output.
2. To prevent sweating
and keep the skin dry.
Sweat can potentiate skin
irritation and scratching
References: Impaired Skin Integrity Nursing Diagnosis & Care Plan. (2023, February 26). Retrieved from
https://www.nursetogether.com/impaired-skin-integrity-nursing-diagnosis-care-plan/