NCP Ineffective Tissue Perfusion
NCP Ineffective Tissue Perfusion
NCP Ineffective Tissue Perfusion
Alabang Zapote Rd., Pamplona Las Pias City COLLEGE OF NURSING NURSING CARE PLAN Name of Patient: Jaime Gamlanga ASSESSMENT SUBJECTIVE: Ok namanangpakiramd amko, as verbalized by the client. OBJECTIVE: Alert, awake and responsive (+)spontaneous, non-labored breathing Capillary refill less than 4 seconds (+) weakness (+) weak, irregular pulse rate & rhythm Temp 36.4C PR 64bpm RR 20cpm BP 120/80 mmHg NURSING DIAGNOSIS Ineffective tissue perfusion related to impaired transport of O2 across capillary membrane as evidenced by weak, irregular pulse rhythm. Age: 79 years old PLANNING After 8 hours of nursing intervention, client will demonstrate increased perfusion with manifestation of regular pulse characteristics. Sex: M INTERVENTIONS Established Rapport Monitored and recorded vital signs Monitored and recorded Intake and Output Diagnosis: Cardiac Arrythmia RATIONALE To gain clients trust and cooperation To establish baseline data To determine fluid volume relative to oxygen transportation and circulation Quiet atmosphere conducive to rest alleviates stress which aids the heart in proper function Activities that requires too much work load leads to heart stress These medications promote proper circulation and transportation of O2 Rm. / Bed No.: 504 EVALUATION Goal met. After 8 hours of nursing intervention, the client manifested regular and consistent pulse rhythm.
Cautioned to avoid activities that increase the hearts work load Administered Carvedilol, Erdosteine and KaliumDurule as ordered