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NCP - Activity Intolerance

The patient is experiencing ineffective tissue perfusion related to vasoconstriction of blood vessels. The nurse will monitor the patient's blood pressure, instruct a low salt diet, assist with position changes, and administer antihypertensive medication as ordered. Interventions also include promoting early ambulation, exercising the legs, and instructing the patient to avoid rubbing the affected extremity in order to improve the patient's tissue perfusion and control their blood pressure.

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Princess Alane Moreno
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145 views5 pages

NCP - Activity Intolerance

The patient is experiencing ineffective tissue perfusion related to vasoconstriction of blood vessels. The nurse will monitor the patient's blood pressure, instruct a low salt diet, assist with position changes, and administer antihypertensive medication as ordered. Interventions also include promoting early ambulation, exercising the legs, and instructing the patient to avoid rubbing the affected extremity in order to improve the patient's tissue perfusion and control their blood pressure.

Uploaded by

Princess Alane Moreno
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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DATE/

CUES NEED NURSING DIAGNOSIS PATIENT OUTCOME INTERVENTIONS IMPLEMENTATIONS EVALUATION


TIME
SUBJECTIVE: Ineffective tissue perfusion At the end of nursing o Monitor blood 1
o “Nahihilo ako” as related to vasoconstriction interventions, the pressure every four
verbalized by the of blood vessels patient will be able to hours.
patient. demonstrate improved R: To know baseline
OBJECTIVE: perfusion as evidenced BP.
o PR: 85bpm Rationale: by: o Instruct to eat low 4
o RR: 22 bpm Arteriolar circulation is a. Peripheral pulses fat, low salt diet.
o Temp: 37.1C disrupted by alternating present R: To reduce edema

o BP: 130/110 mmHg segments of constriction b. Pink skin color that may activate renin-
and dilation. The c. Moist oral angiotensin-
o Tissue edema present
vasospastic action causes mucosa, and aldosterone system.
pitting +2
damage to the blood d. Absence of o Assist with position 2
o Weak peripheral pulses
vessels by decreasing their tissue edema changes.
on extremities
blood supply. R: Gently repositioning
o Pale, dry, and poor skin
patient from supine to
turgor
sitting/standing position
o Dry oral mucosa
can reduce the risk of
o Laboratory test:
orthostatic BP
CBC: 50% Het
changes.
(increased)
o Administer anti- 3

hypertensive drug,
as ordered.
R: To control BP and to
avoid other
coplications. 5
o Promote early
ambulation as soon
as client is able and
with physician’s
approval.
R: Short frequent walks
are determined to be
better forextremities
and prevention of
pulmonary
complications than one
long walk. If client is
confined to bed,
ensure ROM
exercises. 6
o Elevate legs when
in bed or chair as
indicated.
R: Reduces tissue
swelling and rapidly
empties superficial and
tibial veins preventing
overdistention and
thereby increasing
venous return. 7
o Initiate active or
passive exercises
while in bed (e.g.,
flex/extend/rotate
foot periodically).
Assist with gradual
resumption of
ambulation (e.g.,
walking 10 min/hr)
as soon as client is
permitted out of
bed.
R: These measures
are designed to
increase venous return
from lower extremities 8
o Instruct client to
avoid
rubbing/massaging
the affected
extremity.
R: This activity
potentiates risk of
fragmenting/dislodging
thrombus causing
embolization, and
increasing risk of
complications. 9
o Increase fluid intake
to atleast
2000mL/day, within
cardiac tolerance.
R: Dehydration
increase blood
viscosity and venous
stasis, predisposing to
thrombus formation. 10
o Promote
active/passive ROM
exercises.
R: Exercise prevents
venous stasis and
further circulatory
compromise. 11
o Provide oxygen
therapy as
necessary.
R: This saturates
circulating hemoglobin
and augments the
efficiency of blood that
is reaching the
ischemic tissues. 12
o Position patient
properly in a semi-
Fowler’s to high
Fowler’s tolerated. Princess Alane
R: Upright positioning Marie T.
promotes improved Moreno St.N
alveolar gas
exchange.

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