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The patient is experiencing ineffective peripheral tissue perfusion due to edema. With hypertension, the heart is forced to pump against rising peripheral resistance which reduces blood supply to organs like the kidneys. This causes vasospasm in the kidneys, increasing blood flow resistance and decreasing glomerular filtration. As a result, sodium reabsorption and fluid retention occur, causing fluid to shift from blood vessels to tissues and lead to edema. Short term nursing interventions include assessing edema, monitoring intake/output to determine fluid retention, and encouraging ambulation. Long term the patient will demonstrate increased perfusion as evidenced by an absence of edema.
The patient is experiencing ineffective peripheral tissue perfusion due to edema. With hypertension, the heart is forced to pump against rising peripheral resistance which reduces blood supply to organs like the kidneys. This causes vasospasm in the kidneys, increasing blood flow resistance and decreasing glomerular filtration. As a result, sodium reabsorption and fluid retention occur, causing fluid to shift from blood vessels to tissues and lead to edema. Short term nursing interventions include assessing edema, monitoring intake/output to determine fluid retention, and encouraging ambulation. Long term the patient will demonstrate increased perfusion as evidenced by an absence of edema.
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The patient is experiencing ineffective peripheral tissue perfusion due to edema. With hypertension, the heart is forced to pump against rising peripheral resistance which reduces blood supply to organs like the kidneys. This causes vasospasm in the kidneys, increasing blood flow resistance and decreasing glomerular filtration. As a result, sodium reabsorption and fluid retention occur, causing fluid to shift from blood vessels to tissues and lead to edema. Short term nursing interventions include assessing edema, monitoring intake/output to determine fluid retention, and encouraging ambulation. Long term the patient will demonstrate increased perfusion as evidenced by an absence of edema.
Hak Cipta:
Attribution Non-Commercial (BY-NC)
Format Tersedia
Unduh sebagai DOC, PDF, TXT atau baca online dari Scribd
diagnosis Explanation Planning Intervention Rationale Expected Outcome S- Ø Short term: 1.Assess the site - to obtain Short term: O- the patient Ineffective With After 4° of of edema. baseline data The patient shall may manifest: Peripheral hypertension, nursing and determine have verbalized Tissue Perfusion the cardiac intervention, the the severity of understanding of - periorbital r/t Edema system can patient will be the condition. condition and edema become able to verbalize 2.Monitor I & O - To determine if enumerate overwhelmed understanding of the Intake is pharmacologic - bipedal edema because the condition and equal to the and non- - skin is tight and heart is forced to enumerate output. Thereby pharmacologic shiny and flaky pump against pharmacologic determining if regimen. rising peripheral and non- there is still fluid resistance. This pharmacologic retention. reduces blood regimen. Long Term: supply to organs 3.Monitor - To obtain particularly the Long Term: patient’s vital The patient shall patient’s kidneys. signs have baseline data Vasospasm in After 3 days of demonstrated the kidney nurse- patient 4.Encourage - To promote increased increases blood interaction, the ambulation as venous return perfusion as flow resistance, patient will often as evidenced by leading to a demonstrate possible. absence of decreased increased edema. -to promote glomerular perfusion as 5.Instruct patient venous return; filtration. Thus evidenced by to elevate legs reduce edema sodium absence of when sitting. reabsorption and edema. fluid retention 6.Instruct a low - To reduce occurrence of takes place. Due salt low fat diet. fluid retention to an increased permeability, fluid shifting occurs from intravascular to interstitial spaces causing edema.