Nursing 101 Medical Surgical Nursing I

Problem # 2 Risk for Inadequate Tissue Perfusion r/t an Addisonian crisis

General Goal: Patient will have adequate tissue perfusion
Expected Patient Outcome(s): The patient will
1.) Demonstrate adequate tissue perfusion as individually appropriate on the day of care.
2.) Be stable and have vital signs within the clients normal range on the day of care.

Nursing Interventions Rationale Patient Responses to Interventions

1a _____________________________ _____________________



1b.





1c


.






Nurse will inspect for pallor,
cyanosis, mottling, and cool or
clammy skin.
Nurse will investigate sudden
changes or continued alterations
in mentation such as anxiety,
confusion, lethargy, and stupor

Nurse will encourage active or
assist with passive leg
exercises.
2a Nurse will monitor
respirations, noting work of
breathing
1. Systemic vasoconstriction results
from cardiac output & may be
evidenced by decrease skin
perfusion (Doenges, Moorhouse &
Murr, 2010).
2. Cerebral perfusion is directly
related to cardiac output & is
influcenced by electrolyte &
acid-base variations, and
hypoxia (Doenges, Moorhouse
& Murr, 2010).
3. Enhances venous
return, reduces venous
stasis. (Doenges,
Moorhouse & Murr,
2010).
4. Cardiac pump failure &
ischemic pain may precipitate
respiratory distress (Doenges,
Moorhouse & Murr, 2010).
1. Patient displays no signs of systemic
vasoconstriction. No nursing interventions made.
Complete.
2. Patient exhibited no alterations in mental
status. No nursing interventions made. Complete.
3. Patient did 15 leg raises in bed independently.
Tolerated exercise well. Complete.
4. Patient had a respiratory rate of 16. Within
normal limits, Complete.


2b


2c










Evaluation: Summarize patient progress toward expected outcomes. What revisions would you make: Patient maintained adequate
tissue perfusion during day of care. Patient displayed no signs or symptoms of inadequate tissue perfusion. Patient was cooperative
and performed active leg exercises. Patients vital signs remained throughout the day. No nursing interventions were implemented.
______________________________________________________________________________________________________


________________________________________________________________________________________________________
Nurse will take patients blood
pressure every 4 hrs
5. Monitors for trends. Can be
indicative of inadequate tissue
perfusion (Doenges, Moorhouse,
& Murr, 2010).
5.Patients blood pressure was taken every 4 hours.
Patients blood pressure was maintained within normal
limits. No nursing interventions needed. Complete.
Nurse will monitor ECG
6. ECG may be due to a tissue
perfusion issue (Doenges,
Moorhouse, & Murr,2010).
6.Patients ECG showed atrial fibrillation. Patient given
Digoxin. Patient responsed well. Patient reverted back to a
normal sinus rhythm. Complete.