NANDA-Nursing Plan 00228 Risk for ineffective peripheral 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
目次
Risk for ineffective peripheral tissue perfusion 00228
Nursing Diagnosis: Risk for ineffective peripheral tissue perfusion
Definition: A condition in which blood circulation to the periphery is likely to decrease and may impair health.
This nursing diagnosis is a risk-type diagnosis, so it is a state where peripheral tissue circulation is about to become poor or at risk.
This “ineffective peripheral tissue circulation risk state” is the preliminary stage, but for patients who have already developed symptoms, please plan the actual type of “ineffective peripheral tissue circulation”.
1. Subject to risk for ineffective peripheral tissue perfusion
・Heart failure ★Please refer to “Decreased cardiac output”.
・Signs of left heart failure: dyspnea at rest, orthopnea, paroxysmal nocturnal dyspnea, cold peripheral sensation, cyanosis, pink foamy phlegm (with wheezing and coughing), heart murmur (3.4 sounds), hypotension (cardiac source) sexual shock)
・ Symptoms of right heart failure: edema (congestion of the systemic circulation system), pleural effusion, ascites
・Right heart failure often occurs secondary to left heart failure. Mechanism of left heart failure → pulmonary hypertension → right heart failure
・The causes of right heart failure that do not occur secondary to left heart failure include valve diseases such as the tricuspid valve and pulmonary valve, and pulmonary diseases such as pulmonary hypertension and COPD.
・Muscle decrease, subcutaneous fat increase
・Autonomic imbalance
・Trauma, fracture
・Gypsum fixation
·smoking
・Sedentary lifestyle
・Secondary Raynaud’s disease (There is a causative disease, followed by blood flow disturbance. Also called Raynaud’s syndrome)★１
・ Autoimmune diseases with Raynaud’s phenomenon:
Scleroderma, systemic lupus erythematosus, mixed connective tissue disease, rheumatoid arthritis, polymyositis/dermatomyositis
・ Obstructive arterial disease: ASO (arteriosclerosis obliterans), Buerger’s disease
·Diabetes
・High blood pressure
・ Blood disease: cryoglobulinemia
· Vibration disorders (intimal disorders of peripheral blood vessels and peripheral neuropathy due to vibration of tools, machines, and devices) → Raynaud’s phenomenon
・ Drug side effects
・Primary Raynaud’s disease (no underlying disease that causes it) ★１
★1 What is Raynaud’s disease?
1) pathology
Induced by cold stimuli and mental stress, spasms of small arteries of the fingers and toes occur. Arteriolar spasm results from an imbalance between vasorelaxant and vasoconstrictor factors. Raynaud’s phenomenon is a change of the skin to white or bluish-purple due to spasm of these small arteries.
When there is no underlying disease that causes the disease and the identity of the disease is unknown, it is called primary Raynaud’s disease, and when there is an underlying disease, it is called secondary Raynaud’s disease (Raynaud’s syndrome).
2) Symptoms
・The tip becomes white from the part where the fingertip is.
Redness when blood flow returns
・Numbness and pain
3) Treatment
・Do not cool your fingers (gloves)
・Do not use cold water
・Avoid stress and overwork
・Drug therapy (some are not covered by insurance): Vasodilators (Ca channel blockers), antiplatelet drugs
・If you have an ulcer, Ripple intravenous injection, Prostandin intravenous injection
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 (peripheral)
・Circulatory dynamics
・Risk control: hypertension, blood clots, smoking, lipid abnormalities
・Early detection of abnormalities
Knowledge: health promotion, healthy eating, prescribed activities, weight management
・Self-management: hypertension, dyslipidemia, diabetes, peripheral venous disease
・Physical aging
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 ○○.”
・Can describe the effects of prescribed instructions (diet, exercise, oral medication). You can continue at home.
・Efforts will be made to detect abnormalities at an early stage.
• Describe the handling of needles and insulin in diabetes management.
・If you have discomfort symptoms such as difficulty breathing or pain, you can consult a medical professional.
*Nurse goals include:
• Help manage underlying underlying conditions.
・If lifestyle habits are a factor, support the prescribed instructions (diet, exercise, oral medication) so that they can be continued at home.
・Efforts will be made to detect abnormalities at an early stage.
・Promote understanding of how to handle needles and insulin in diabetes management.
・Relieves discomfort such as breathing difficulty and pain.
・Listen to concerns and try to alleviate them.
4. nursing plan
1) Observation Plan 《OP》
・Age, gender
* Decrease in muscle mass in old age
* Collagen disease is more common in women
・Medical history, current disease history
* Heart disease, valve disease
*Pulmonary diseases such as pulmonary hypertension and COPD
*Diabetes
*Blood disease, coagulation system abnormality
* Obstructive arterial disease
* Autoimmune diseases: SLE, scleroderma, connective tissue disease, rheumatism, polymyositis, dermatomyositis
* Vibration disorder (due to occupation)
* Cast fixation, fracture
*Autonomic imbalance
・Raynaud phenomenon
・Raynaud’s phenomenon appears due to cold stimulation. Blood flow returns by removing stimulation
・Peripheral cold sensation, cyanosis
・Weight, obesity, lifestyle habits: life with a lot of oil and sugar intake, smoking, excessive drinking and daily drinking
・vital signs
・Blood pressure, pulse pressure, left-right difference, pulse deficit
・Heart rate (bradycardia, tachycardia), pulse rate (bradycardia, tachycardia), difference between heartbeat and pulse
・SPO2
・ Auscultation: lung murmur (pulmonary edema), heart murmur (valve disease 3.4 sounds)
・Physical findings
・Edema, cyanosis, peripheral coldness
・Image inspection
・ XP, CT: pleural effusion, ascites, fracture, etc.
・Load test
・ Walk for 6 minutes
・Strength: MMT
・ADL, IADL: How far can you go on your own, are you willing to do it yourself?
・Caregiver’s ability to care
·Subjective symptoms:
・ Dyspnea, pink foamy sputum, productive cough,
・Peripheral sensory disturbance
・Disturbed consciousness (hyperglycemia, etc.)
・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
・Bleeding tendency: PLT (platelets), PT (prothrombin time), APTT (partial thromboplastin)
・Hyperglycemia: 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.
Cardiogenic shock symptoms
・Low blood pressure, loss of consciousness, decreased urine output, etc.
・electro-cardiogram
・Arrhythmia
・ Oral medicine (Try following the 6Rs. Check what you are taking and what risks you are taking.)
・Treatment plan
・Cognitive impairment, compliance
・Blood glucose measurement, use of insulin, degree of skill acquisition
・Presence or absence of understanding of how to dispose of medical waste at home
2) Action plan 《TP》
・Provide care that considers safety, comfort, and independence.
・Minimize the use of the monitor, and early detection of abnormalities such as arrhythmia when wearing the monitor.
・Arrange tubes so that they are not bent or pulled out.
・Arrange the environment so that the degree of rest can be maintained.
・Help and manage internal medicines.
・Improve the circulation of the extremities with foot baths, hand baths, massages, etc.
・If the patient has no sensation in the periphery, have the patient be careful not to bump into the patient, and consider appropriate footwear. Also, prepare the environment to prevent falls.
– Patients with a bleeding tendency or who are taking antiplatelet drugs should be careful not to fall or bump (other patients are not allowed to bump).
・Regularly check that circulation is maintained when the cast is fixed.
・Watch over blood glucose measurement and insulin self-injection procedures, and provide support such as explanations when necessary.
・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.
・Perform passive exercise (joint range of motion exercise) to maintain good limb position.
・In order to prevent a decline in ADL, from the viewpoint of daily life rehabilitation, we will have them do what they can do by themselves, and create an environment where they can do it by themselves.
Install touch-ups, L-shaped fences, portable toilets, etc. as necessary.
・Check for painful symptoms (dyspnea, pain) and try to alleviate the pain. If there is anxiety, listen carefully and try to reduce anxiety.
・If the person is unable to do necessary things by themselves such as hygiene care and eating due to symptoms, help them.
・Compensate for self-care that cannot be done due to injury.
・Provide an environment to support what you can do on your own at home. Consult with a social worker or care manager to make adjustments so that you can receive the services you need.
3) Education plan 《EP》
・Explain Raynaud’s phenomenon to the patient and caregivers before discharge from the hospital. Instruct the patient to see a medical institution as soon as symptoms appear during home care.
・Explain what you want the child to do at home to prevent it from getting worse.
・Use lukewarm water to wash dishes and do not cool them down.
– Warm up with gloves and socks.
Avoid stress and overwork
・Improve circulation with foot and hand baths. Warm up in the bathtub.
・If you have a dull feeling in your hands and feet, be careful not to hit them. If bacteria enter from the place where you hit it, it will be a big problem.
・Keep your skin and nails clean, and wear shoes that match your size.
・Beware of low-temperature burns (when using a hot water bottle, etc.)
Do not self-discontinue and take the prescribed medicine.
・Explain how to handle needles at home when self-monitoring blood glucose or self-injecting insulin.
Since it cannot be disposed of in general garbage, put it in a non-penetrating container such as a bottle and take it with you when you visit a medical institution (medical institution where you have been prescribed needles).
・Please let us know immediately if you have any symptoms such as discoloration of your fingertips or loss of sensation while the cast is in place.
・Please let us know if you have any subjective symptoms (pain, palpitations, shortness of breath, breathing difficulty, etc.).
・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.
・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.
・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.
・Give advice on adapting to lifestyle changes.
・Consult with a social worker or care manager so that you can receive the services you need to live at home.
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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