Name of Patient: R.N.P.

B Age/Sex: 40-F Room/Bed #: 307-2

DATE & CUES NEED NURSING PATIENT INTERVENTION IMPLEMEN- EVALUATION

Subjective: “Naa na Ineffective tissue After 6 hours of  Establish rapport. March 5, 2020
gyod ni sa among perfusion related to nursing R: To easily gain @ 3:00 PM
pamilya ang taas nga N impaired transport intervention, client
BP.” As verbalized by U of oxygen across will be able to:
cooperation to
client.
1 GOAL MET.
the patient. T capillary membrane After 6 hours of nursing
M R as evidenced by a. Demonstrate  Monitor Hgb levels intervention, the patient
A I weak, irregular increase perfusion R: Low levels was able to:
R Objective: T pulse rhythm. with manifestation reduced the uptake
C - Capillary refill I of regular pulse of oxygen at the a. Demonstrated increased
H test more than 2 O characteristics alveolar capillary 9 perfusion with strong
seconds N Rationale: such as strong membrane and peripheral pulses and vitals
5, - (+) weakness Blood is a peripheral pulses, oxygen delivery to were within normal range
- (+) weak, - connective tissue and vitals within the tissues. with pulse rate of 84 bpm;
2 irregular pulse compromised of a normal range;
0 rate & rhythm M liquid extracellular  Administer IV fluids b. reported necessary
2 - family history of E matrix termed as b. report necessary as ordered. lifestyle changes as
0 high blood T blood plasma lifestyle changes; R: Volume therapy verbalized by the patient,
pressure A which dissolves and “After nako manganak, di
@ - Vital signs: B and suspends
may be required to
maintain adequate
3 nako mag hinambid kaayo,
8:00 AM CR: 62 bpm O multiple cells and c. identify factors filling pressures and ug gamayan nako ang
PR: 60 bpm L cell fragments. It that improve optimize cardiac sigeg tindog sa balay
BP: 140/90 I carries oxygen circulation. output needed for namo; “ and
mmHg C from the lungs and tissue perfusion.
RR: 17 cpm nutrients from the c. identified factors that
Temp.: 35.0°C gastrointestinal  Monitor BP for improves circulation by
- Medications: tract. The oxygen orthostatic changes. patient’s verbalization of
Hydralazine and nutrients R: Stable BP is “Mag stretching-stretching
IVTT subsequently necessary to 5 nako kada-adlaw ani.”
Methyldopa diffuse from the maintain adequate
250mg tab blood into the tissue perfusion.
interstitial fluid and
then into the body  Assist with position
cells. Insufficient changes.
arterial blood flow R: Slowly changing
causes decreased from a supine to
nutrition and sitting/standing
oxygenation at the position can reduce
cellular level. the risk for 4
orthostatic BP
Reference: change. Older
Wayne, G. (2019). patients are more
Ineffective Tissue susceptible to such
Perfusion Nursing drops in pressure
Care Plan - with position Vianah Eve A. Escobido
Nurseslabs. changes. St. N
Retrieved March
10, 2020, from  Promote
https://nurseslabs.c active/passive ROM
om/ineffective- exercises.
tissue-perfusion/% R: These therapies
3famp promote increased
venous return,
7
contributing to
improved cardiac
output.

 Administer
medication as
 prescribed to treat
underlying problem.
Such as
hypertensives to
reduce systemic
vascular resistance
and optimize
2
cardiac output and
perfusion.
R: These
medications
facilitate perfusion
for most causes of
impairment.

 Educate patient on
the examples of
lifestyle factors that
can improved tissue
perfusion such as
avoiding crossed
legs at the knee
when sitting,
changing positions
at frequent intervals, 6
rising slowly from a
supine/sitting to
standing position,
and avoiding
smoking.
R: These measures
reduce venous
compression or
 venous stasis and
arterial
vasoconstriction.

 Instruct the patient

Reference:
Nursing Diagnoses:
Definitions and
Classification. (2015).
Mosby, an imprint of
Elsevier Inc.