Assessment Actual/ Abnormal Cues: -Client verbalized pain on right leg -Pulse rate of 64 bpm -elevated creatinin level of indicating decreased blood flow to the kidney -elevated Troponin I indicating damage to the heart Nursing Diagnosis Ineffective peripheral tissue perfusion related to interruption of arterial blood flow as evidenced by claudication, weak pulse, elevated creatinin level. Definition: Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level Source: Rationale Precipitating Predisposing 62y.o. female Increased Serum cholesterol, DM Desired Outcome After 3 days of nursing intervention, the patient will be able to: 1.Verbalize understanding of condition, therapy and side effects of medication. Nursing Intervention Justification Evaluation After 3 days of nursing intervention, the patient was able to: Independent :
accumulation/deposit of lipids in the walls of the coronary arteries Narrowing, blockage of the lumen of the coronary artery
1a.Determine factors related to situation such as history of thrombus or emboli formation, diabetes, lipid abnormalities. 1b. Identify changes related to peripheral alterations incirculation (vital signs, pain, etc.) 1c. Discourage massaging calf
Risk Factor: -diabetes mellitus -coronary artery disease/ischemic heart disease Strength: -Family support -Spiritual aspect -Compliance to medication
Nurses Pocket Guide: Diagnosis, Prioritized Interventions and Rationales, 11th edition
Pain on right leg (claudication), low pulse rate (64bpm), elevated creatinin level of Elevated Troponin I
Source: Source: Black, J.M. and Hawks, J.H. (2005). Medical-Surgical Nursing: Clinical management for positive outcomes, 7th ed., Elsevier Inc.
2.Demonstrate behavior/lifestyl e changes to improve circulation (relaxation techniques, exercise, dietary program).
2a. Demonstrate/ encourage use of relaxation activities/ exercises 2b. Review dietary restrictions (low salt, low fat diet) 3a. Encourage early ambulation when possible. -Elevate legs when sitting. 3b.Discourage sitting/ standing for long periods, wearing constrictive clothing and crossing legs. 3c.Elevate head of bed
3.Demonstrate increased perfusion (strong peripheral pulses, absence of pain on right leg).
Collaborative 3d. Administer medications with caution 3e. Assist with/prepare for surgical procedures
3e. To improve peripheral circulation and relieve excessive tissue pressure NANDA 10th ed.