NURSING CARE PLAN # 5

DATE IDENTIFIED

January 22, 2018

NURSING ASSESSMENT

Subjective cues:

Objective cues:
 Restlessness
 Changes in motor response
 Edema
 Altered LOC

NURSING DIAGNOSIS

Ineffective myocardial tissue perfusion related to altered blood circulation

PLANNING

Long-term: After 16 hours of nursing intervention, Patient Popeye will be able to

maintain maximum tissue perfusion to vital organs.

Short term: After 30 minutes of nursing intervention, Patient Popeye will be able to
remains free of side effects from the medications used to achieve adequate cardiac
output.
IMPLEMENTATION

INTERVENTION RATIONALE
Ongoing Assessment
1. Assessed patient Popeye for signs Particular clusters of sign and symptoms
of decreased tissue perfusion. occur with differing causes. Evaluation
provides a baseline for future comparison.

2. Assessed patient Popeye for Early detection of the source facilitates

probable contributing factors quick, effective management.
related to temporarily impaired
arterial blood flow.
3. Reviewed laboratory data (ABGs, Blood clotting studies are being used to
BUN, creatinine, electrolytes, conclude or make sure that clotting factors
international normalized ratio, and stay within therapeutic levels. Gauges of
prothrombin time or partial organ perfusion or function. Irregularities
thromboplastin time) if in coagulation may occur as an effect of
anticoagulants are utilized for therapeutic measures.
treatment.
Independent Interventions

4. Submitted patient to diagnostic A variety of tests are available depending

testing as indicated. on the cause of the impaired tissue
perfusion. Angiograms, Doppler flow
studies, segmental limb pressure
measurement such as ankle-brachial
index (ABI), and vascular stress testing
are examples of these tests.
5. Checked patient Popeye for optimal Sufficient fluid intake maintains adequate
fluid balance. Administered IV fluids filling pressures and optimizes cardiac
as ordered. output needed for tissue perfusion.
6. Maintained optimal cardiac output. This ensures adequate perfusion of vital
organs.
7. Administered nitroglycerin (NTG) This enhances myocardial perfusion.
sublingually for complaints of
angina.
8. Positioned patient Popeye in semi- Upright position is recommended to
Fowler’s to high-Fowler. reduce preload and ventricular filling when
fluid overload is the cause.
9. Monitored patient Popeye blood It is necessary for the nurse to assess how
pressure, pulse, and condition well the patient is tolerating current
before administering cardiac medications before administering cardiac
medications such as angiotensin medications; do not hold medications
converting enzyme (ACE) without physician input. The physician
inhibitors, digoxin, and beta- may decide to have medications
blockers such as carvedilol. administered even though the blood
Notified the physician if heart rate pressure or pulse rate has lowered.
or blood pressure is low before
holding medications.
10. Monitored ST-Segment To determine changes in myocardial
continuously tissue Perfusion.
11. Monitored signs of tissue perfusion To identify the early signs of impaired
adequacy. perfusion.
12. Checked symptoms for chest pain. Low cardiac output can further decrease
myocardial perfusion, resulting in chest
pain.
13. Provided calm and quiet Reduces stimulation and release of stress-
environment. related which can cause increase in
myocardial workload.
Dependent Interventions For optimal care
14. Assisted with treatment of
underlying conditions (medications, fluid
replacement, nutrients, treatment) as per
doctor’s order to improve tissue
perfusion/organ function

15. Administered medications as per To help reduce the complication

doctor’s order
Interdependent Intervention

14. Associated patient Popeye to heart A thoroughly monitored exercise program

failure program or cardiac can improve both functional capacity, and
rehabilitation program for left ventricular function
education, evaluation, and guided
support to increase activity and
rebuild life.
Health Teachings
Early recognition of symptoms facilitates
15. Educated patient Popeye’s family early problem solving and prompt
and about the disease process, treatment.
complications of disease process,
information on medications, need
for weighing daily, and when it is
appropriate to call doctor.
16. Aided patient Popeye’s family to Transition to the home setting can cause
adapt daily living patterns to risk factors such as inappropriate diet to
establish life changes that will reemerge.
maintain improved cardiac
functioning in the patient.
 17. Rendered health teachings such A. Straining for a bowel movement further
as: impairs cardiac output and it demands
a. Avoid straining. more oxygen.
b. Deep breathing exercises B. Deep breathing exercises help in lung
c. Eat foods rich in iron expansion.
C. to increase the capacity of the RBC to
carry oxygen throughout the body.
18. Explained the importance of Smoking cessation advice and counsel
smoking cessation and avoidance given by nurses can be effective, and
of alcohol intake. should be available to patients to help stop
smoking.

EVALUATION

Goal not met patient Popeye wasn’t able to maintain maximum tissue perfusion,
as evidenced by dry skin, presence of edema, altered Level of Consciousness.

DATE EVALUATED

January 23, 2018