NANDA-Nursing Plan Area4 activity/rest / 看護計画 領域11 安全/防御

NANDA-Nursing Plan 00201 Risk for ineffective tissue perfusion

NANDA-Nursing Plan 00201 Risk for ineffective tissue perfusion

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 4 Activity/Rest
production, storage, consumption, or balance of energy resources
Class 4 Cardiovascular/Pulmonary Response: Circulatory Support for Activity/Rest – Respiratory Mechanism

00201 Risk for ineffective tissue perfusion

Nursing diagnosis: 00201 Risk for ineffective tissue perfusion
Definition: A condition in which blood circulation to the brain tissue is likely to decrease and may impair health.

There are several diseases that reduce cerebral blood flow.
These include cerebral artery stenosis, cerebral artery malformation, cerebral artery occlusion, space-occupying lesions in the brain, and decreased stroke volume due to heart disease.
Among them, cerebrovascular disease is the leading cause of death.
When I was a student, I was in 3rd place, but in 2020 statistics, I am in 4th place.
By the way, in 2020, the first place is malignant neoplasm (27.6%), the second place is heart disease (15%), the third place is senescence, and the fourth place is cerebrovascular disease.
I often see what is coming to the top in the cause of death in clinical.
Let’s start with a review of cerebrovascular disease.

1. cerebrovascular disease

1) concept

A state in which neurological symptoms rapidly develop due to occlusion or rupture of cerebral blood vessels.
Ischemic cerebrovascular disease includes cerebral infarction.
Hemorrhagic cerebrovascular disorders include cerebral hemorrhage and subarachnoid hemorrhage.

2) Causes and risk factors

・Aging
・male
・High blood pressure
・Dyslipidemia
・Diabetes
・Non-valvular atrial fibrillation
・Hyperuricemia
・Blood system abnormalities (DIC, thrombocytosis)
·smoking
・Large drinking
・obesity
・cold

3) Symptoms

・Movement disorders
・Sensory disturbance
・Dysarthria
・Higher brain dysfunction (aphasia/agnosia)
Consciousness disorder: cerebral edema, cerebral herniation
・Visual field disorder
・Nausea/vomiting
・Stigma

4) Inspection

(1) Cerebral infarction
・MRI (diffusion-weighted image with high signal in the hyperacute stage of cerebral infarction)
・CT (low density after acute stage)
・CTA/MRA (stenosis or occlusion of blood vessels)
(2) Cerebral hemorrhage
・CT (high absorbance region)

5) Treatment

(1) Cerebral infarction
① Hyperacute phase (within 6 hours of injury):
Thrombolytic therapy (rt-PA), neuroprotective agents (edaravone), anti-cerebral edema therapy (glycerol), antiplatelet therapy, endovascular therapy
*Do not use endovascular treatment or glycerol for lacunar infarction
② Chronic phase:
・Atherogenic stroke: management of risk factors, antiplatelet therapy, surgical treatment
・Cardiogenic cerebral infarction: anticoagulant therapy
Lacunar infarction: management of risk factors, antiplatelet therapy, blood pressure control

2. Adaptation for ineffective cerebral circulation risk status

・Bleeding tendency
・DIC
・Vascular disorder
・Brain tumor
・cerebral hemorrhage
・subarachnoid hemorrhage
・cerebral infarction
・Atherothrombotic cerebral infarction
・ Cardiogenic cerebral embolism
・ Lacunar infarction
・Arteriosclerosis
Diseases that cause arteriosclerosis: diabetes, dyslipidemia
・Cerebral artery malformation
・Transient ischemic attack
・Cardiac disease with decreased stroke volume: dilated cardiomyopathy, sick sinus syndrome, myocardial infarction
・Heart disease with thrombosis (bacterial mass): Infective endocarditis *Common after tooth extraction
・Arrhythmia: atrial fibrillation (thrombus forms and flies to the brain)
・Carotid artery stenosis

3. aim setting

1) Goal setting by linkage (published in the second half of NOC)

*Linkage has the role of connecting NANDA (diagnosis) and NOC (results).
・Tissue circulation (brain)
・Organizational circulation
・Blood coagulation
・Severity of hypertension
・Risk control (thrombosis, stroke)
・Efficacy of heart pump function

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do XX”,
For example, “The patient will be able to do ○○.”

・(Person/family member) can describe “ACT FAST” for early detection of symptoms.
・Be able to describe lifestyle habits to prevent recurrence and work on lifestyle improvement.
・To be able to describe points to consider when undergoing examinations and endovascular treatment. In addition, if there is an abnormality after the examination, it can be reported to the medical staff.
・Able to maintain daily life by using self-help tools.
・Consult with social workers and care managers and receive necessary service introduction.  

*Nurse goals include:

・Efforts will be made to detect abnormalities at an early stage through vital signs and monitors.
・Teach TIA patients for early detection (according to ACT FAST, have them understand the need to see a doctor as soon as symptoms appear and receive early treatment.)
・It can lead to lifestyle improvement to prevent recurrence.
・Listen to concerns about examinations and endovascular treatment, and work to alleviate anxiety.
・Work to relieve discomfort.
・Compensate for self-care that cannot be done due to injury.
・Watch over the process of acceptance of body image changes such as paralysis. It also provides advice on adapting to lifestyle changes.
・If a disability remains, consult with a social worker or care manager to make arrangements so that the necessary services can be received.  

4. nursing plan

1) Observation Plan 《OP》

・Age, gender
・Medical history, current disease history
・Lifestyle habits: a lifestyle that consumes a lot of oil and sugar, smoking, excessive drinking and drinking every day
・Body weight and degree of obesity
·vital signs
・Blood pressure, pulse pressure, left-right difference
・Heart rate (bradycardia, tachycardia), pulse rate (bradycardia, tachycardia), difference between heartbeat and pulse
・SPO2
・Image inspection
・MRI
・MRA/CTA
・CT
・Physical findings, neurological symptoms
・ Paralysis (site, range, degree): motor paralysis, sensory paralysis
・Biasopia
・ Nausea and vomiting
・ Consciousness disturbance, fainting
· Neural reflex disorder
・Subjective symptoms: headache, nausea, dizziness, darkening
・Event: Tooth extraction (possibility of forming a bacterial mass in the atrium), post-surgery (possibility of DVT in the lower extremities and wearing a bullet brace)
・Venous blood data
· PLT (platelets), PT (prothrombin time), APTT (partial thromboplastin)
・Blood sugar: GLU, HbA1C
・ Neutral fat, total cholesterol, HDL, LDL
・Symptoms indicating bleeding tendency
・ Bleeding, petechiae, purpura, hematuria, hematochezia, difficulty in hemostasis
・symptoms indicating high blood pressure
· Nose bleeding, increased blood pressure, etc.
·electro-cardiogram
· Arrhythmia (atrial fibrillation)
・ Oral medicine (Try following the 6Rs. Check what you are taking and what risks you are taking.)
・Cyanosis, cold sensation
・Treatment plan
・When performing CTA, confirm the contrast agent consent form and confirm the history of shock
*MRA can be imaged without a contrast agent
・When performing MRI and MRA, check the prohibited items
(pacemaker, cerebral artery clip, metal in the body, permanent makeup)
・Risk confirmation in preoperative examination
・Confirmation of written consent (individual or family member): consent for examination, consent for anesthesia, consent for surgery, consent for restraint, etc.
· Confirmation of DNAR
・Course before, during, and after surgery
(★ 1. Nursing plan “postoperative recovery delay” also introduces perioperative nursing.
Please take a look at it once. )
・vital signs
・Bleeding volume, drainage volume, urine volume
・Insert
・Presence or absence of monitor abnormal values (ECG, SPO2, ETCO2, P, BP)
・Oxygen administration
・Administration device, dosage (at rest/exertion), SPO2, blood gas data, state of consciousness
・Oxygen cylinder usage status, whether the person can replace it
・Numbers and symptoms that are indicators of hemodynamics
・Cyanosis
・Decreased urine volume,
・productive cough
・Sputum: quantity, properties (color, consistency)
・Moisture balance
・Oral medicine
・Cognitive impairment, compliance

2) Action plan 《TP》

・Provide care that considers safety, comfort, and independence.
・Arrange tubes so that they are not bent or pulled out.
・Arrange the environment so that the degree of rest can be maintained.
・Keep cigarettes and other flammable items at the time of hospitalization. (If you have brought it with you, explain to yourself and your family not to bring it into the hospital, and ask them to take it home.)
・Help and manage internal medicines.
・Prepare for examinations and preoperative examinations. If there is a clinical path, follow the path for showering, shaving, etc.
・Check the instructions on the medicines that need to be stopped before surgery or examination, and withdraw them.
・Create a postoperative bed. Oxygen, monitors, electric blankets, foot pumps, drip sticks, syringe pumps, infusion pumps, etc.
・If restraint is unavoidable, check whether there are any skin problems due to restraint for each shift. Also, daily, assess the need for restraints and remove them promptly if they can be removed.
・When using a ventilator, double-check the set values and actual measurements. Check for circuit breakage. Check the amount of distilled water in the humidifier. Check the insertion length and cuff of the intubation tube. Secure the intubation tube without tension.
– If sedation associated with the use of a ventilator is being used, a sedation scale will be used for evaluation. Adjust the amount of sedative accordingly according to the instructions on the scale. Check monitor values. Report any abnormal values to the leader and attending physician.
・Mouth care should be performed by two people during the insertion of the intubation tube. Observe skin problems caused by fixation.
・Recheck the syringe pump usage and replacement procedure, and pay attention to free flow.
・When using oxygen, check the oxygen administration device, dosage, and state of consciousness. Follow the route to make sure oxygen is being administered. Prepare the environment so that it will not be pulled.
・Check the remaining amount of the cylinder, and replace it if the remaining amount is low. Even for patients who self-manage, ask them to check the amount when using (sometimes they forget to open the bottle while walking).
・According to the doctor’s instructions, measure the urine volume at the designated time. Check and record CVP measurement, in-out balance.
・Perform passive exercise (joint range of motion exercise) to maintain good limb position.
・Check for painful symptoms and work to alleviate pain. If there is anxiety, listen carefully and try to reduce anxiety.
・Compensate for self-care that cannot be done due to injury. .
・If convulsion or twitching occurs, record the time of onset, duration, and whether it is general or local, and report to the doctor.
・Watch over the process of acceptance of body image changes such as paralysis. It also provides advice on adapting to lifestyle changes.
・If a disability remains, consult with a social worker or care manager to make arrangements so that the necessary services can be received.  

3) Education plan 《EP》

・”ACT FAST”★1 will be explained.
・If you have subjective symptoms (pain, palpitations, shortness of breath, etc.), please let us know immediately.
・Explain that pain should not be tolerated and should be reported. Explain that analgesics can be used if needed.
・Explain the purpose, goals, and treatment course of the treatment plan.
・Explain what should be observed during treatment.
・Explain items that require self-management such as drug suspension and smoking cessation in the treatment plan.
・If there is a need to improve lifestyle habits, check the policies of doctors, nutritionists, and physical therapists, and provide support and explanations in accordance with the policies.
・If you need contrast imaging, surgery, anesthesia, or restraint, please explain and fill out a consent form (basically, a doctor will do it).
・When starting restraint, explain the reason, site, and usage time (three requirements) to the family.
・When performing CTA, confirm the contrast agent consent form and confirm the history of shock
・When performing MRI or MRA, confirm the prohibited matters and ask the patient to remove any removable items such as contact lenses, dentures, and rings.
・Risk confirmation in preoperative examination
・Confirm the degree of understanding of the course before, during, and after surgery. If necessary, explain again or ask a doctor.
・Listen to concerns about examinations and surgeries. Explain what happened and what you can do if necessary.
・Explain the dangers associated with removal of tubes, and explain treatment methods that prevent removal.
・Explain that fire is strictly prohibited when oxygen is used.
・Explain how to connect to an oxygen cylinder and how to use it.
– When using oxygen at home, the same applies to fire bans, and explain that it is necessary to keep at least 2 meters away from fire.
・In oral treatment, follow the doctor’s instructions and explain the need to follow the dosage and duration.
・Explain to the patient and family members not to bring cigarettes or flammable items into the hospital.
・Watch over the process of acceptance of body image changes such as paralysis. It also provides advice on adapting to lifestyle changes.
・If a disability remains, consult with a social worker or care manager to make arrangements so that the necessary services can be received.  

★ 1 What is ACT FAST?

It is an indicator for early detection of stroke (stroke refers to cerebral infarction and cerebral hemorrhage) indicated by the American Stroke Association.
It is said that 10-15% of people will have a cerebral infarction within 3 months after a transient ischemic attack.
People who have had a transient ischemic attack should see a doctor as soon as possible if the following symptoms appear.
ACT stands for action, to “act”.
“F” is for Face
Confirmation of facial paralysis Ask “Try saying yee”.
If the corners of the mouth do not rise, there is paralysis.
“A” is Arm
Confirmation of arm paralysis
“Close your eyes, raise your palms up to your shoulders, and keep it there.”
I ask. If the arm falls down, there is paralysis.
“S” is for Speech
Confirmation of dysarthria
If you have no voice or can’t speak well, you may be paralyzed.
“T” is Time
Confirmation and recording of time
 Previous facial paralysis, A hand paralysis, S dysarthria,
Record when it happened.
*The time from onset is important for the treatment of cerebral infarction. If detected early, thrombolytic therapy is indicated (not subject to precedent).
And please see an outpatient immediately.

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.
Yutaka Okaniwa. (2003). Disease can be seen VOL.2 Cardiology. Medic Media Co., Ltd.
Yutaka Okaniwa. (2007). Illness can be seen VOL.4 Respiratory organs. 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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