Nursing Care Plan for Altered Peripheral Tissue Perfusion r/t Heart Failure

Nursing Care Plan for Heart Failure 

 Nursing Diagnosis : Altered Peripheral Tissue Perfusio

Congestive heart failure (CHF) is a term used by cardiologists to describe a patient whose heart does not pump enough blood out to the rest of the body to meet the body's demand for energy.

This can be due to either a heart that pumps well but is very insufficient (due to a structural problem), or it can be a result of a weak heart muscle that does not pump a normal amount of blood to the body.

Either situation will lead to backup of blood and fluid into the lungs if the left side of the heart is the problem or backup of blood and fluid into the liver and veins leading into the heart if the right side of the heart is problem.

It is not uncommon for both sides of the heart to fail at the same time and cause backup into both systems simultaneously.


Nursing Diagnosis : Altered Peripheral Tissue Perfusion related to decreased blood flow in the peripheral area secondary to decreased cardiac output.
characterized by; capillary filling is slow, pale or cyanotic nail color.

Goal: peripheral tissue perfusion can be improved (adequate) with expected outcomes:
  • The skin is warm and dry.
  • Strong pulse, capillary refill strong.
  • Normal vital signs.
  • No cyanosis or pale.

Interventions :
  • Monitor vital signs, capillary refill, skin color, skin moisture, edema, peripheral O2 saturation in the area.
  • Increase bed rest during the acute phase.
  • Emphasize the importance of avoiding straining especially during defecation.
  • Collaboration in the delivery of oxygen and inotropic drugs.
Rationale :
  • Knowing adequacy of peripheral perfusion.
  • Restrictions activity lowers oxygen and nutrient needs of peripheral areas.
  • Avoid increasing hypoxia in peripheral tissues.
  • Oxygen increase alveolar oxygen concentration, thereby improving tissue hypoxemia.
  • Inotropic drugs to increase myocardial contractility.


Source : http://nandacareplan.blogspot.com/2014/11/heart-failure-5-nursing-diagnosis-and.html

Popular posts from this blog

Administering a Metered Dose Inhaler (self administration)

Medical Equipments: Medication Administration Record (MAR) Medication with Dropper Emesis Basin (optional) Non-sterile Gloves Tissue Nursing Actions: Check the allergies that patient may have Determine the written order on MAR Wash hands Check patient’s identification armband Explain the procedures to the patient and provide privacy Ask patient to blow nose unless contraindicated Inform the patient that he/she may feel a burning sensation to the mucosa or a choking sensation, or both, as the drop trickles back into the throat Place patient in a supine position and hyperextend the neck and position the head to the site that facilitates the drop reaching the expected site Instruct the patient to breathe through mouth Squeeze medications into the dropper Insert the nasal drops about 3/8 inch into nostril and keep the tip of the dropper away from the sides of the nares. Instill the medication as prescribed and observe for signs and discomforts Ask the patient to maintain supine position fo
Read more

Nursing School Rankings

by: Milos Pesic The US News & World Report and the National Institutes of Health (NIH) Report on Research Funding conduct nursing school rankings to measure the status of quality of different nursing schools nationwide. Various factors affect how nursing school rankings are determined but it all serves the purpose of providing more information to anyone in search of a nursing school. As you evaluate different leaning institutions for your nursing education, nursing school rankings should supplement your own research. First, determine which specific nursing program you wish to enter and then based on that look at nursing schools in your chosen location that offer that specific program. You can use nursing school rankings to find out the areas of strength of a particular school and if it matches your interest and needs. In general, organizations determine nursing school rankings by gathering data through surveys that are prepared by professors and other scholars. Survey respondents c
Read more

10 Beneficial Foods for Maintaining Healthy Skin and Prevent Wrinkles

Image
Tight skin is the dream of all people, especially women. In addition to routine maintenance, you also need a balanced diet to have healthy skin. To prevent skin wrinkles, some foods are very beneficial when consumed. Most anti - wrinkle foods rich in antioxidants, which neutralize the effects of free radicals that attack collagen and elasticity of skin tissue. Some of these habits can be anti- wrinkling skin : Drink 4-6 glasses of water every day, wearing sunglasses, a hat, and sunscreen when in the sun, and of course do not smoke. Here are some foods that are beneficial for maintaining healthy skin, especially the skin to prevent wrinkles : 1. Blueberries Blueberries and other berries contain powerful antioxidants called polyphenols. Eat one serving or 1/2 cup every day, if possible choose organic berries. 2. Salmon Salmon and other cold water fish rich in omega - 3 fatty acids, which delays wrinkles by preventing inflammation and as a skin lubricant. Eat about 3 - ounce fish this typ
Read more