Nursing Care Plan

Assessment Actual/ Abnormal Cues: -Client verbalized pain on right leg -Pulse rate of 64 bpm -elevated creatinin level of indicating decreased blood flow to the kidney -elevated Troponin I indicating damage to the heart Nursing Diagnosis Ineffective peripheral tissue perfusion related to interruption of arterial blood flow as evidenced by claudication, weak pulse, elevated creatinin level. Definition: Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level Source: Rationale Precipitating Predisposing 62y.o. female Increased Serum cholesterol, DM Desired Outcome After 3 days of nursing intervention, the patient will be able to: 1.Verbalize understanding of condition, therapy and side effects of medication. Nursing Intervention Justification Evaluation After 3 days of nursing intervention, the patient was able to: Independent :

accumulation/deposit of lipids in the walls of the coronary arteries Narrowing, blockage of the lumen of the coronary artery

Intravascular clot formation Decreased arterial blood flow

1a.Determine factors related to situation such as history of thrombus or emboli formation, diabetes, lipid abnormalities. 1b. Identify changes related to peripheral alterations incirculation (vital signs, pain, etc.) 1c. Discourage massaging calf

1.To assess causative/ contributing factors.

1b. To monitor client status.

Risk Factor: -diabetes mellitus -coronary artery disease/ischemic heart disease Strength: -Family support -Spiritual aspect -Compliance to medication

Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales, 11th edition

Pain on right leg (claudication), low pulse rate (64bpm), elevated creatinin level of Elevated Troponin I

1c. To prevent embolization.

Ineffective peripheral tissue perfusion

-Positive outlook towards the disease

Source: Source: Black, J.M. and Hawks, J.H. (2005). Medical-Surgical Nursing: Clinical management for positive outcomes, 7th ed., Elsevier Inc.

2.Demonstrate behavior/lifestyl e changes to improve circulation (relaxation techniques, exercise, dietary program).

2a. Demonstrate/ encourage use of relaxation activities/ exercises 2b. Review dietary restrictions (low salt, low fat diet) 3a. Encourage early ambulation when possible. -Elevate legs when sitting. 3b.Discourage sitting/ standing for long periods, wearing constrictive clothing and crossing legs. 3c.Elevate head of bed

2a.To reduce tension level

2b. To promote wellness

3.Demonstrate increased perfusion (strong peripheral pulses, absence of pain on right leg).

3a. To enhance venous return.

3b. To maximize tissue perfusion

3c. To increase gravitational blood flow.

Collaborative 3d. Administer medications with caution 3e. Assist with/prepare for surgical procedures

3d.To maximize tissue perfusion.

3e. To improve peripheral circulation and relieve excessive tissue pressure NANDA 10th ed.