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Risk For Decreased Cardiac Tissue Perfusion

The patient presented with dizziness, weakness, and a blood glucose level of 127 mg/dl. Tests showed thickened heart valves without restriction and signs of small vessel ischemia. The plan was for the patient to maintain tissue perfusion through lifestyle changes, identify factors affecting circulation, and demonstrate normal sensations after nursing intervention. Evaluation after 3 days aimed to see improved vital signs, lab tests, and ability to maintain perfusion and identify lifestyle changes.

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Karina Madriaga
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724 views3 pages

Risk For Decreased Cardiac Tissue Perfusion

The patient presented with dizziness, weakness, and a blood glucose level of 127 mg/dl. Tests showed thickened heart valves without restriction and signs of small vessel ischemia. The plan was for the patient to maintain tissue perfusion through lifestyle changes, identify factors affecting circulation, and demonstrate normal sensations after nursing intervention. Evaluation after 3 days aimed to see improved vital signs, lab tests, and ability to maintain perfusion and identify lifestyle changes.

Uploaded by

Karina Madriaga
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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ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Risk for decreased After 3 days of nursing Assess for signs of Evaluation of Ineffective After 3 days of nursing
- Pt. verbalized cardiac tissue perfusion intervention, the patient decreased tissue Tissue Perfusion defining intervention, the patient
dizziness and related to altered arterial will be able to: perfusion. characteristics provides a was able to:
generalized body blood flow - maintain baseline for future - maintain
weakness maximum tissue comparison. maximum tissue
- No chest pain perfusion to vital perfusion to vital
- No headache organs, as Assess for probable Early detection of the organs, as
- No difficulty of evidenced by vital contributing factors source facilitates quick, evidenced by vital
breathing signs, laboratory, related to temporarily effective management. signs, laboratory,
- No vomiting and diagnostic impaired arterial blood and diagnostic
tests within flow. tests within
Objective normal range normal range
- CBG (10:30 am): Explain all procedures and Understanding expected
127 mg/dl After 8 hours of nursing treatments. events and sensations can After 8 hours of nursing
- Trop T.: 0.03 – intervention, the patient help eliminate anxiety intervention, the patient
0.1mg/ml will be able to: associated with the was able to:
- identify factors unknown. - identify factors
2D ECHOCARDIOGRAM that improve that improve
- Thickened circulation Check for optimal fluid Sufficient fluid intake circulation
anterior mitral - identify necessary balance. Administer IV maintains adequate filling - identify necessary
valve leaflet lifestyle changes fluids as ordered. pressures and optimizes lifestyle changes
without - engages in cardiac output needed for - engages in
restriction of behaviors or tissue perfusion. behaviors or
motion. actions to actions to
- Thickened aortic improve tissue Note urine output. Reduce renal perfusion improve tissue
cusps without perfusion may take place due to perfusion
restriction of - verbalizes and vascular occlusion. verbalizes and
motion. Aortic demonstrates demonstrates normal
annular normal Maintain optimal cardiac This ensures adequate sensations and
calcification sensations and output. perfusion of vital organs. movement as appropriate
movement as
COLOR FLOW DOPPLER appropriate Administer nitroglycerin This enhances myocardial
STUDY (NTG) sublingually for perfusion.
- Trivial mitral complaints of angina.
regurgitation,
aortic Maintain oxygen therapy To enhance myocardial
regurgitation, and as ordered. perfusion.
tricuspid
regurgitation, Provide knowledge on Knowledge of causative
reversed E/A normal tissue perfusion factors provides a
inflow velocity and possible causes of rationale for treatments
rate. impairment.

CONCLUSION: Encourage change in These measures reduce


- Thickened lifestyle that could venous
anterior mitral improve tissue perfusion. compression/venous
valve leaflet with (avoiding crossed legs at stasis and arterial
trivial mitral the knee when sitting, vasoconstriction.
regurgitation. changing positions at
- Aortic sclerosis frequent intervals, rising
with trivial aortic slowly from a
regurgitation. supine/sitting to standing
- Trivial tricuspid position, avoiding
regurgitation. smoking, reducing risk
factors for atherosclerosis
CT SCAN REPORT: [obesity, hypertension,
- IMPRESSION: dyslipidemia, inactivity]).
CHRONIC SMALL
VESSEL ISCHEMIC Teach patient to Early assessment
CHANGES. recognize the signs and facilitates immediate
symptoms that need to treatment.
Medical History: be reported to the
- Hospitalized on healthcare provider.
2/8/11
- CC: SOB, angina,
and weakness in
both upper and
lower extremities
- Increase in blood
pressure
- Above normal
cholesterol level:
234 mg/dl
- Chest PAL:
atherosclerotic
aorta

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