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Nursing Care Plan for Ineffective Tissue Perfusion

The nursing care plan summarizes a patient presenting with dizziness, headache, edema in the lower extremities, cold clammy skin, and a blood pressure of 140/100. The nursing diagnosis is ineffective tissue perfusion related to vasoconstriction of blood vessels. Short term goals include increasing tissue perfusion within 1 hour and long term goals include understanding vasoconstriction of blood vessels within 2 hours. Planned nursing interventions include monitoring vital signs, range of motion exercises, rest, administering antihypertensive drugs and magnesium sulfate as ordered.

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Arianne Nicole Pinuela
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287 views1 page

Nursing Care Plan for Ineffective Tissue Perfusion

The nursing care plan summarizes a patient presenting with dizziness, headache, edema in the lower extremities, cold clammy skin, and a blood pressure of 140/100. The nursing diagnosis is ineffective tissue perfusion related to vasoconstriction of blood vessels. Short term goals include increasing tissue perfusion within 1 hour and long term goals include understanding vasoconstriction of blood vessels within 2 hours. Planned nursing interventions include monitoring vital signs, range of motion exercises, rest, administering antihypertensive drugs and magnesium sulfate as ordered.

Uploaded by

Arianne Nicole Pinuela
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PHINMA UNIVERSITY OF ILOILO

COLLEGE OF ALLIED HEALTH SCIENCES


Nursing Department

NURSING CARE PLAN


NURSING
ASSESSMENT NURSING DIAGNOSIS PLANNING RATIONALE EVALUATION
INTERVENTIONS
OBJECTIVE: Ineffective tissue perfusion SHORT TERM: INDEPENDENT:
Nahihilo ako. Masakit ang related to vasoconstriction of After 1hour client will be able - Monitor vital signs  After 1hour client
batok ko.” as verbalized blood vessels to manifest increased tissue paticularly  To identify physical will be able to
perfusion. blood responses associated manifest increased
pressure. with medical tissue perfusion.
conditions.
- Perform assistive passive
range of motion.  ROM promotes
improved blood
SUBJECTIVE: - Provide quiet and restful circulation.
- Edema environment.
noted on LONG TERM:  It conserves
lower After 2 hours will be able to energy/lowers tissue  After 2 hours will be
extremities (grade 2) understand to understand oxygen demand. able to understand to
vasoconstriction of blood understand
DEPENDENT
- cold, vessels.
- Administer antihypertensive  Antihypertensives vasoconstriction of
clammy skin help decrease and blood vessels.
drugs as ordered.
noted. control blood
- Administer Magnesium pressure.
- capillary refill within 6
sulfate as ordered.
seconds  Magnesium sulfate
prevents or controls
- BP: seizures in pre-
140/100 eclampsia brought
about by vasospasm
secondary to
vasoconstriction of
blood vessels.

PREPARED BY: ARIANNE NICOLE PINUELA

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