NANDA-NursingPlan Area 11 Safety/Defense

NANDA-Nursing Plan 00086 Risk for peripheral neurovascular dysfunction

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.


Area 11 Safety/Defense
Category 2 Bodily injury Bodily harm or injury
Peripheral neurovascular dysfunction risk status

00086 Risk for peripheral neurovascular dysfunction

Nursing Diagnosis: Risk for peripheral neurovascular dysfunction
Definition: A condition in which the circulatory, sensory, and motor functions of the limbs are susceptible to disruption and may impair health.

1. Indications for “Risk for peripheral neurovascular dysfunction”


・Orthopedic surgery (artificial joint replacement, plate fixation, external fixation, intramedullary nail fixation, etc.), casts, bandages, braces
・Compression stockings and elastic bandages (circulatory disturbance due to wearing → delay or deterioration of tissue recovery, allergies due to materials)
・Restrained
・Fixtures for long periods of time in the same position, bedridden, surgical positions, and postural maintenance
・Arteriosclerosis obliterans (stenosis or blockage of peripheral arteries due to arteriosclerosis)
・Fracture, injury, burn

2. aim setting

Goal setting by linkage (listed in the second half of the NOC)
* “Linkage” has the role of connecting “NANDA”, “NIC” and “NOC” (link means “connection”).

1) Linkage achievements

・Blood coagulation (0409)
(Definition: time for blood to coagulate within the normal range)
・Fracture healing (1104)
(Definition: extent to which cells and tissues recover from bone damage)
・Postoperative recovery: recovery period (2304)
(Definition: Degree of physical function, mental function, role function from the recovery room after anesthesia to the final outpatient visit)
Neurological Conditions: Spinal Nervous System Sensory/Motor Functions (0914)
(Definition: functions of the spinal nervous system that transmit sensory and motor stimuli)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do ○○”,
For example, “The patient will be able to do ○○.”
・If you feel abnormal sensations (pain, numbness, paralysis) or skin abnormalities, you can tell the medical staff.
・Keeps wounds and wounds clean (do not touch with dirty hands).

※I think that the following goals can be set as action goals for nurses.
・Prevents circulatory and neurological disorders caused by the same body position such as prolonged bed rest.
・Help keep the injured area clean and aid recovery.
・Prevent postoperative complications and neuropathy by early ambulation and observation. In addition, early detection of abnormalities is carried out.

3. nursing plan

1 >> Observation plan <OP>

・Coagulation system: Grasping of bleeding tendency, grasping of the presence or absence of bleeding
・PLT: Normal value 180,000 to 350,000, thrombocytopenia at 100,000/μL or less
・ATPP-activated partial thromboplastin: normal value 28-38 seconds
・PT prothrombin time: normal value 10 to 15 seconds or longer
 PT prothrombin time activity %: normal value 80-100%
・D-dimer’ (secondary fibrinolysis): No clear standard (500ng/ml to 1μg/ml or less)
・FDP (fibrin degradation product): Normal value less than 10 μg/ml
・Anemia: Understanding the presence or absence of bleeding
  ・Hb: Normal value 14g/dl or more for men, 12g/dl or more for women
  ・RBC: Normal value 4.1 million/μl or more for men, 3.8 million/μl or more for women
  ・Ht: normal value: 40-50% for men, 36-45% for women
・Subcutaneous bleeding, purpura, petechiae
〈Trauma, disease, etc.〉
Bruises, open bones, bone infections
・Fracture healing process
・purpura, hematoma
・Hematuria
・Hematochezia
・Hemoptysis
・Hematemesis
·edema
・Infection of surrounding tissues
・Depth of burn
・Burn pain
・Pulse rate ・Blood pressure ・Arrhythmia
・Stable hemodynamics, peripheral coldness, urine output, cyanosis
・Body temperature
・Respiratory rate, respiratory rhythm, lung noise
・Electrolyte balance
・Water intake, rehydration, food intake, blood sugar level
・Organizational integrity
– Neurovascular integrity (cyanosis of extremities, hypoesthesia)
・Wound healing
・Cognition
・Disturbance of consciousness
・Delirium
・Postoperative complications (atelectasis, pneumonia, pain, drainage to dressing material, drain drainage, wound infection, suture failure, venous thrombosis, pulmonary embolism, nausea, vomiting, paralytic ileus, constipation, depression)
・Deep tendon reflex
・Autonomous functions
・ Sensation of upper body skin
・Sensation of the skin of the lower body
・Upper body strength, lower body strength
・Muscle relaxant
・involuntary movements
・Circulatory disorders due to restraints
・ Hypoesthesia

2 》 Action plan 《TP》

・Provide positioning and assistance to maintain cleanliness and fixation of the wound after orthopedic surgery (artificial joint replacement, plate fixation, external fixation, intramedullary nail fixation, etc.).
・Keep casts, bandages, and braces clean and safe.
・When wearing a cast, monitor and manage peripheral circulation.
・If you are instructed to change bandages or gauze, do so cleanly.
・Properly secure implants such as drains and balloons.
・Dispose of wastewater cleanly.
・To prevent circulatory disturbance due to elastic stockings, wear them correctly.
 Refer to the Toray product page for the correct mounting method → *Revised on September 1, 2005 (2nd edition) (toray.co.jp)
・When using a restraint, open it every few hours to check if there are any skin problems or scratches on the restraint area.
・For patients who have been in the same position for a long time or who are bedridden, the position should be changed regularly.
– Observe the postoperative course of the pressure site for patients who used a surgical position or a immobilizer to maintain the position.
・Perform a foot bath for patients with arteriosclerosis obliterans (stenosis or blockage of peripheral arteries due to arteriosclerosis).
・Perform a foot bath for patients with diabetic peripheral neuropathy.

3 >> Education  plan 《EP》

・If you feel any abnormalities such as pain or numbness, please call the nurse.
・Using pamphlets, etc., explain the postoperative course and complications.
・For patients with peripheral neuropathy such as diabetes, be careful not to hurt the foot (the wound may become necrotic and amputated).
explain.
・Instruct patients with a tendency to bleed to be careful of bruising.
・Instruct the patient to maintain a level of rest during fracture reduction and after surgery.

References

T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Yumiko Ohashi, Hajime Yoshino, Naoki Aikawa, Sumi Sugawara. (2008). Nursing Learning Dictionary (3rd Edition). Gakken Co., Ltd. (Gakken).

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