Question

A.- Plan a nursing care plan to promote PERFUSION and prevent complications such as CLOTTING or altered IMMUNITY; Plan should have PROBLEM, DIAGNOSIS, PLAN, INTERVENTION AND EVALUATION OF PLAN.

B-.How can nurse's use clinical judgment to assess laboratory data and signs and symptoms to prioritize care for patients with vascular problems?

C- Show three ways nurses can Implement nursing interventions to decrease the psychosocial impact of living with chronic vascular disease.

Answer 1

Ans) A) Nursing diagnosis:

Ineffective Tissue Perfusion:

Altered affinity of hemoglobin for oxygen
Decreased hemoglobin concentration in blood.

Nursing goals:

- Patient identifies factors that improve circulation.
- Patient identifies necessary lifestyle changes.
- Patient exhibits growing tolerance to activity.
- Patient no further worsening/repetition of deficits.
- Patient engages in behaviors or actions to improve tissue perfusion.

Nursing intervention & Rationale:

- Submit patient to diagnostic testing as indicated. A variety of tests are available depending on the cause of the impaired tissue perfusion. Angiograms, Doppler flow studies, segmental limb pressure measurement such as ankle-brachial index (ABI), and vascular stress testing are examples of these tests.

- Check for optimal fluid balance. Administer IV fluids as ordered. Sufficient fluid intake maintains adequate filling pressures and optimizes cardiac output needed for tissue perfusion.

- Note urine output. Reduce renal perfusion may take place due to vascular occlusion.

- Maintain optimal cardiac output. This ensures adequate perfusion of vital organs.

- Consider the need for potential embolectomy, heparinization, vasodilator therapy, thrombolytic therapy, and fluid rescue. These facilitate perfusion when interference to blood flow transpires or when perfusion has gone down to such a serious level leading to ischemic damage.

Ineffective Tissue Perfusion: Cardiovascular

- Administer nitroglycerin (NTG) sublingually for complaints of angina. This enhances myocardial perfusion.

- Maintain oxygen therapy as ordered. To enhance myocardial perfusion.

Ineffective Tissue Perfusion: Cerebral

- When patient experiences dizziness due to orthostatic hypotension when getting up, educate methods to decrease dizziness, such as remaining seated for several minutes before standing, flexing feet upward several times while seated, rising slowly, sitting down immediately if feeling dizzy, and trying to have someone present when standing. Orthostatic hypotension results in temporary decreased cerebral perfusion.

- Check mental status; perform a neurological examination. Review trend in level of consciousness (LOC) and possibility for increased ICP and is helpful in deciding location, extent and development/resolution or central nervous system (CNS) damage.

- If ICP is increased, elevate head of bed 30 to 45 degrees. This promotes venous outflow from brain and helps reduce pressure.

- Avoid measures that may trigger increased ICP such as coughing, vomiting, straining at stool, neck in flexion, head flat, or bearing down. These will further reduce cerebral blood flow.

- Administer medication as needed. These reduce risk of seizure which may result from cerebral edema or ischemia.

- Control environmental temperature as necessary. Perform tepid sponge bath when fever occurs. Fever may be a sign of damage to hypothalamus. Fever and shivering can further increase ICP.

- Evaluate eye opening. Establishes arousal ability or level of consciousness.

- Evaluate motor reaction to simple commands, noting purposeful and nonpurposeful movement. Document limb movement and note right and left sides individually. Measures overall awareness and capacity to react to external stimuli, and best signifies condition of consciousness in the patient whose eyes are closed due to trauma or who is aphasic. Consciousness and involuntary movement are incorporated if patient can both take hold of and let go of the tester’s hand or grasp two fingers on command. Purposeful movement can comprise of grimacing or withdrawing from painful stimuli. Other movements (posturing and abnormal flexion of extremities) usually specify disperse cortical damage. Absence of spontaneous movement on one side of the body signifies damage to the motor tracts in the opposite cerebral hemisphere.

- Evaluate verbal reaction. Observe if patient is oriented to person, place and time; or is confused; uses inappropriate words or phrases that make little sense. Measures appropriateness of speech content and level of consciousness. If minimum damage has taken place in the cerebral cortex, patient may be stimulated by verbal stimuli but may show drowsy or uncooperative. More broad damage to the cerebral cortex may be manifested by slow reaction to commands, lapsing into sleep when not aroused, disorientation, and stupor. Injury to midbrain , pons, and medulla is evidenced by lack of appropriate reactions to stimuli.

- Provide rest periods between care activities and prevent duration of procedures. Constant activity can further increase ICP by creating a cumulative stimulant effect.

- Reorient to environment as needed. Decreased cerebral blood flow or cerebral edema may result in changes in the LOC.

Ineffective Tissue Perfusion: Peripheral

- Assist with position changes. Gently repositioning patient from a supine to sitting/standing position can reduce the risk for orthostatic BP changes. Older patients are more susceptible to such drops of pressure with position changes.

- Promote active/passive ROM exercises. Exercise prevents venous stasis and further circulatory compromise.

- Administer medications as prescribed to treat underlying problem. Note the response. These medications facilitate perfusion for most causes of impairment.

B) Clinical judgement is the conclusion or enlightened opinion at which a nurse arrives following a process of observation, reflexion and analysis of observable or available information or data.

- Ways to Improve Clinical Judgment
Clinical Practices.
Case Review. Case review is one of the best ways to develop clinical judgment, especially with nurses new to the specialty. ...
Peer Review. Guided peer review is another way in which staff can develop clinical judgment skills.
Reflection
Simulation
Educational Practices.
Dialogue.
Probing Questions.

C) Living with or experiencing a chronic illness can result in many adjustments and changes, such as loss of independence and not being able to do all the active things you used to do or usually enjoy. Anxiety and depression are common in people with chronic physical illness.

- Nurse to educate the patient:

cope with pain or discomfort from your symptoms.
take steps to manage your condition and practice self-care.
adjust to new limitations that your condition puts on your life.
manage increased financial pressures.
cope with feelings of frustration, confusion, or isolation.