Nursing Diagnosis

Ineffective
gastrointestinal
tissue perfusion
related to
interruption of
arterial and venous
blood flow
secondary to
surgical procedure
(Laparoscopic
Cholecystectomy)
As evidenced by:
S Nasusuka ako
as verbalized by
the client.
- Masakit ang tiyan
ko as verbalized
by the client.
O Hypoactive or
absent bowel
sounds
- abdominal
distention
- BP: 110/60 PR:
72, RR: 25 Temp:

Goal and
Objectives
Decrease in oxygen Goal:
resulting in the
After 4 hours of
failure to nourish
nursing
the tissues at the
intervention, the
capillary level.
client will be able to
(Tissue perfusion
demonstrate
problems can exist increased tissue
without decreased
perfusion as
cardiac output;
appropriate as
however, there may evidenced by skin
be a relationship
dry and warm,
between cardiac
peripheral pulses
output and tissue
present/strong, vital
perfusion.)
signs within clients
-Doenges et. al.
normal range ,
TH
(2009), NANDA 9
balanced intake
Edition, F.A. Davis
and output,
Company
absence of edema,
free of pain and
Ischemia is a
discomfort.
decreased supply
of oxygenated
Objectives:
blood to a body
1. After 10 minutes
organ or part. The
of nursing
condition often
intervention, the
marked by pain and client will be able to
organ dysfunction.
maximize tissues
Some causes of
perfusion.
Analysis

Intervention

Rationale

Evaluation
The client
demonstrated
increased tissue
perfusion as
appropriate as
evidenced by skin
dry and warm,
peripheral pulses
present/strong, vital
signs within clients
normal range ,
balanced intake
and output,
absence of edema,
free of pain and
discomfort.

Monitor vital signs

To establish
baseline data

Elevate head of bed To promote

to at least 10
circulation and
degrees and
venous drainage.

The client was able

to maximize tissues
perfusion.

36.0

ischemia are
arterial embolism,
atherosclerosis,
thrombosis and
vasoconstriction.
- Mosbys Medical,
Nursing, & Allied
Health Dictionary
5th Edition

maintain head and

neck in midline or
neutral position.

2. After 10 minutes
of nursing
intervention, the
client will be able to
maintain adequate
perfusion and

Encourage quiet
and restful
atmosphere.

Conserves energy
and lowers tissue
oxygen demands.

Maintain gastric
intestinal
decompression and
measure output
periodically.

Gastric
compression
impairs GI
circulation.

Monitor closely for

signs of bleeding
during surgical
procedures.

Bleeding can lead

to shock.

Monitor closely for

signs of shock.

Bleeding can be a
result of
unmediated
vasodilation.

Note reports of
Provides
nausea and vomiting, comparison with
location/type/intensity current findings.
of pain.
Auscultate bowel

Provides

The client
maintained
adequate perfusion
and circulation of
well-oxygenated
blood.

circulation of welloxygenated blood.

sounds; measure
abdominal girth,
ascertain customary
waist/belt level; Note
presence of blood.

comparison with
current findings.

Observe for
symptoms of
peritonitis, ischemic
colitis and abdominal
angina.

Provides
comparison with
current findings.

Review baseline
ABGs, electrolytes,
BUN/Crea.

Provides
comparison with
current findings.

Determine duration
of problem/
frequency of
recurrence,
precipitating, and
aggravating factors.

Provides
comparison with
current findings.

Identify changes
related to systemic or
peripheral alterations
in circulation (signs
of metabolic
imbalances, pain,
and changes in

Establishes
baseline for
assessing
improvement/
changes.

organ function).
3. After 10 minutes
of nursing
intervention, the
client will be able to
verbalize basic
understanding of
disease process
and treatment with
at least two
reasons with 100%
accuracy.

Discuss the risk

factors and potential
outcomes of
cholelithiasis.

Information
necessary for client
to make informed
choices and
commit to lifestyle
changes as
appropriate.

Review signs and

symptoms of
cholelithiasis (e.g.
RUQ pain). Discuss
how to prevent and
evaluate this
situation and when to
seek medical care.
Have the client
identify appropriate
interventions.

Recognition or
understanding of
these signs and
symptoms and
timely intervention
will and client in
avoiding
recurrences and
preventing
complications.

Encourage
Verbalization
discussion of feelings allows client to
regarding prognosis. openly express his
feelings, helping to
provide a clear
indication of clients
perception of
himself and his

The client
demonstrated
understanding of
disease process
and treatment with
at least two
reasons with 100%
accuracy.

problem.
Identify necessary
changes in lifestyle
and assist client to
corporate disease
management into
ADLs

Encourages client
involvement
awareness and
responsibility for
own health,
promotes wellness.

Review specific
dietary changes or
restrictions with client
(decrease
cholesterol).

Reduces risk of
recurrence and
promotes
understanding and
prevention.

Demostrate /
encourage use of
relaxation techniques
and exercises.

To decrease
tension level.