Nursing Care Plan | NCP Disc Surgery

Nursing diagnosis ineffective tissue perfusion related to diminished or interrupted blood flow—edema of operative site, hematoma formation, hypovolemia

Possibly evidenced by
Paresthesia or numbness
Decreased range of motion (ROM) or muscle strength

Desired Outcomes/Evaluation Criteria—Client Will
Neurological Status
Report or demonstrate normal sensations and movement as appropriate.

Nursing intervention with rationale:
1. Check neurological signs periodically and compare with baseline. Assess movement and sensation of hands and arms (cervical) and lower extremities and feet (lumbar).
Rationale: Although some degree of sensory impairment is usually present, changes in neurological assessments may reflect development or resolution of spinal cord edema or tissue inflammation due to damage to motor nerve roots from surgical manipulation. Assessment findings may also indicate tissue hemorrhage that causes spinal cord compression. Spinal cord compression requires prompt medical evaluation and intervention.

2. Keep client flat on back for several hours, per protocal.
Rationale: Pressure to operative site reduces risk of hematoma.

3. Monitor vital signs. Note skin color, warmth, and capillary refill.
Rationale: Hypotension, especially postural, with corresponding changes in pulse rate may reflect hypovolemia from blood loss, restriction of oral intake, and nausea and vomiting.

4. Monitor intake and output (I&O) and wound drains, such as Jackson-Pratt or Hemovac, if used.
Rationale: Fluid balance indicates circulatory status and replacement needs. Excessive or prolonged blood loss requires evaluation and ongoing assessments to continually determine and provide prompt and appropriate intervention.

5. Visually check and gently palpate operative site for swelling. Inspect dressing for excess drainage. Test drainage for glucose if cerebrospinal fluid (CSF) leakage is suspected
Rationale: Changes in contour of operative site suggest hematoma or edema formation. Inspection may reveal frank bleeding or dura leak of CSF, thus requiring prompt intervention. CSF will test positive for glucose.

6. Assess extremities—particularly lower extremities—for redness, swelling, and pain.
Rationale: Redness, swelling, and pain in the extremities suggest complications associated with immobility including deep vein thrombosis (DVT).

7. Administer intravenous (IV) fluids or blood, as indicated.
Rationale: Fluid replacement depends on the degree of hypovolemia and duration of oozing, bleeding, or leakage of CSF.

8. Monitor blood counts—hemoglobin (Hgb), hematocrit (Hct), and red blood cells (RBCs).
Rationale: These laboratory tests help establish fluid status and the need for fluid and blood product replacement. They also indicate effectiveness of fluid resuscitation interventions.

9. Apply and maintain schedule for wearing anti-embolic hose or sequential compression devices.
Rationale: Anti-embolic hose, sequential compression devices, and related products reduce the risk for venous stasis in lower extremities.

Nursing Diagnosis for Thrombophlebitis | Ineffective Peripheral Tissue Perfusion

Nursing diagnosis: ineffective peripheral tissue Perfusion related to decreased blood flow and venous stasis (partial or complete venous obstruction)

Possibly evidenced by

Tissue edema, pain

Diminished peripheral pulses, slow or diminished capillary refill

Skin color changes—pallor, erythema

Desired Outcomes/Evaluation Criteria—Client Will

Tissue Perfusion: Peripheral

Demonstrate improved perfusion as evidenced by peripheral pulses present, equal skin color, and temperature normal and absence of edema.

Engage in behaviors or actions to enhance tissue perfusion.

Display increasing tolerance to activity.

Nursing care plan intervention with rationale:

1. Evaluate circulatory and neurological studies of involved extremity, both sensory and motor. Inspect legs from groin to foot for skin color and temperature changes as well as edema. Note symmetry of calves; measure and record calf circumference. Report proximal progression of inflammatory process and traveling pain.

Rationale: Symptoms help distinguish between thrombophlebitis and DVT. Redness, heat, tenderness, and localized edema are characteristic of superficial involvement. Note: Unilateral edema is one of the most reliable physical findings in DVT. Calf vein involvement is associated with absence of edema; femoral vein involvement is associated with mild to moderate

edema; and iliofemoral vein thrombosis is characterized by severe edema.

2. Examine extremity for obviously prominent veins. Palpate gently for local tissue tension, stretched skin, and knots or bumps along course of vein.

Rationale: Distention of superficial veins can occur in DVT because of backflow through communicating veins. Thrombophlebitis in superficial veins may be visible or palpable.

3. Assess capillary refill and check for Homans’ sign.

Rationale: Diminished capillary refill usually present in DVT. Note: Homans’ sign is unreliable because it is not present in many clients with DVT.

4. Promote early ambulation.

Rationale: Short, frequent walks are better for extremities and prevention of pulmonary complications than one long walk. If client is confined to bed, ensure range-of-motion exercises.

5. Elevate legs when in bed or chair, as indicated.

Rationale: Reduces tissue swelling and rapidly empties superficial and tibial veins, preventing overdistention and thereby increasing venous return. Note: Some physicians believe that elevation may potentiate release of thrombus, thus increasing risk of embolization and decreasing circulation to the most distal portion of the extremity.

6. Initiate active or passive exercises while in bed, for example, flex, extend, and rotate feet periodically. Assist with gradual resumption of ambulation as soon as client is permitted out

of bed.

Rationale: These measures are designed to increase venous return from lower extremities and reduce venous stasis as well as improve general muscle tone and strength. They also promote

normal organ function and enhance general wellbeing.

7. Caution client to avoid crossing legs or hyperflex at knee, such as seated position with legs dangling or lying in jackknife position.

Rationale: Physical restriction of circulation impairs blood flow and increases venous stasis in pelvic, popliteal, and leg vessels, thus increasing swelling and discomfort.

8. Instruct client to avoid rubbing or massaging the affected extremity.

Rationale: This activity potentiates risk of fragmenting and dislodging thrombus, causing embolization, and increasing risk of complications.

9. Encourage deep-breathing exercises.

Rationale: Increases negative pressure in thorax, which assists in emptying large veins.

10. Increase fluid intake to at least 1,500 to 2,000 mL/day, within cardiac tolerance.

Rationale: Dehydration increases blood viscosity and venous stasis, predisposing to thrombus formation.

Nursing Diagnosis for Myocardial Infarction | Ineffective Tissue Perfusion

Nursing diagnosis: ineffective tissue perfusion related to reduction or interruption of blood flow—vasoconstriction, hypovolemia, shunting, thromboembolic, atherosclerotic plaque formation.

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will

Cardiac Pump Effectiveness

Demonstrate adequate perfusion as individually appropriate, such as skin warm and dry, peripheral pulses present and strong, vital signs within client’s normal range, client alert or oriented, balanced intake and output (I&O), absence of edema, free of pain or discomfort, stable, improving ECG, vitals, and mentation.

Nursing intervention with rationale:

1. Investigate sudden changes or continued alterations in mentation, such as anxiety, confusion, lethargy, and stupor.

Rationale: Cerebral perfusion is directly related to cardiac output and is influenced by electrolyte and acid-base variations, hypoxia, and systemic emboli.

2. Inspect for pallor, cyanosis, mottling, and cool or clammy skin. Note strength of peripheral pulses.

Rationale: Systemic vasoconstriction resulting from diminished cardiac output may be evidenced by decreased skin perfusion and diminished pulses.

3. Monitor respirations, noting work of breathing.

Rationale: Cardiac pump failure and ischemic pain may precipitate respiratory distress; however, sudden or continued dyspnea may indicate thromboembolic pulmonary complications.

4. Monitor intake, noting changes in urine output. Record urine specific gravity, as indicated.

Rationale: Decreased intake or persistent nausea may result in reduced circulating volume, which negatively affects perfusion and organ function. Specific gravity measurements reflect

hydration status and renal function.

5. Assess gastrointestinal function, noting anorexia, decreased or absent bowel sounds, nausea and vomiting, abdominal distention, and constipation.

Rationale: Reduced blood flow to mesentery can produce gastrointestinal dysfunction, such as loss of peristalsis. Problems may be potentiated or aggravated by use of analgesics, decreased

activity, and dietary changes.

6. Encourage active or assist with passive leg exercises, with avoidance of isometric exercises.

Rationale: Enhances venous return, reduces venous stasis, and decreases risk of thrombophlebitis; however, isometric exercises can adversely affect cardiac output by increasing myocardial work and oxygen consumption.

7. Assess for pain in lower extremity and Homans’ sign, erythema, and edema.

Rationale: Indicators of deep vein thrombosis (DVT), although calf pain is not always present.

8. Instruct client in application and periodic removal of antiembolic hose when used.

Rationale: Limits venous stasis, improves venous return, and reduces risk of thrombophlebitis in client who is limited in activity.

9. Apply elastic compression stockings or intermittent pneumatic compression devices, as indicated.

Rationale: May be desired to prevent DVT, especially in client who is unable to be out of bed or cannot ambulate freely.

10. Obtain a 12-lead ECG recording.

Rationale: Determines extension of infarction.

11. Monitor laboratory data, such as ABGs, blood urea nitrogen (BUN), creatinine, electrolytes, and coagulation studies (prothrombin time [PT], activated prothrombin time [aPTT],

clotting times).

Rationale: Indicators of organ perfusion and function. Abnormalities in coagulation may occur as a result of therapeutic measures, such as heparin or Coumadin use and some cardiac drugs.

12. Provide supplemental oxygen as prescribed.

Rationale: Increases oxygen supply to the myocardium.

13. Administer medications, as indicated, for example: Antiplatelet agents, such as aspirin, abciximab (ReoPro),clopidogrel (Plavix), and eptifibatide (Integrilin).

Rationale: Reduces mortality in MI clients and is taken daily. Aspirin also reduces coronary reocclusion after percutaneous transluminal coronary angioplasty (PTCA). IV antiplatelet drugs such as ReoPro and Integrilin are used as adjuncts to PTCA to decrease complication of platelet clumping within stent when placed.

14. Anticoagulants, such as heparin/enoxaparin (Lovenox)

Rationale: Low-dose heparin is given during PTCA and may be given prophylactically in high-risk clients, such as those with atrial fibrillation, obesity, ventricular aneurysm, or history of thrombophlebitis, to reduce risk of thrombophlebitis or mural thrombus formation.

15. Cimetidine (Tagamet), ranitidine (Zantac), and antacids

Rationale: May occasionally be used to reduce or neutralize gastric acid, preventing discomfort and gastric irritation, especially in presence of reduced mucosal circulation.

16. Assist with reperfusion therapy: Administer thrombolytic agents: alteplase (Activase, rt-PA), reteplase (Retavase), streptokinase (Streptase), anistreplase (Eminase), and urokinase (Abbokinase).

Rationale: Thrombolytic therapy is the treatment of choice if angioplasty is not immediately available within 90 minutes. The goal is to restore perfusion to the myocardium.

17. Prepare for procedures such as balloon PTCA, with or without intracoronary stents.

Rationale: Angioplasty is used to open blocked coronary arteries and immediately restore myocardial perfusion. The mechanism includes a combination of vessel stretching and plaque compression and removal of thrombotic material. Intracoronary stents may be placed at the time of PTCA to provide structural support within the coronary artery. Drug-eluting (drug coated) stents may be used to decrease risk of restenosis and improve long-term patency.

18. Transfer to CCU or step-down unit.

Rationale: Depending on client’s condition—degree of heart damage or other chronic health conditions—telemetry or more intensive monitoring and aggressive interventions may be necessary to promote optimum outcome.

Ineffective Peripheral Tissue Perfusion

Nursing Care Plan for Diabetes Mellitus

Ineffective peripheral tissue Perfusion related to decreased arterial flow as evidenced by decreased pulses, pale and cool feet, thick brittle nails, numbness and tingling of feet “when walks 1/4 mile.”

Client Will

1. Verbalize understanding of relationship between chronic disease (diabetes mellitus) and circulatory changes within 48 hr (6/30, 7 p.m.).

2. Demonstrate awareness of safety factors and proper foot care within 48 hr (6/30, 7 p.m.).

3. Maintain adequate level of hydration to maximize perfusion (ongoing), as evidenced by balanced intake/output, moist skin and mucous membranes, and capillary refill less than 3 sec (ongoing).

Nursing Intervention:

1. Elevate feet when up in chair. Avoid long periods with feet in dependent position.

Rationale: Minimizes interruption of blood flow and reduces venous pooling.

2. Assess for signs of dehydration. Monitor intake/output. Encourage oral fluids.

Rationale: Glycosuria may result in dehydration with consequent reduction of circulating volume and further impairment of peripheral circulation.

3. Instruct client to avoid constricting clothing and socks and ill-fitting shoes.

Rationale: Compromised circulation and decreased pain sensation may precipitate or aggravate tissue breakdown.

4. Reinforce safety precautions regarding use of heating pads, hot water bottles, or soaks.

Rationale: Heat increases metabolic demands on compromised tissues. Vascular insufficiency alters pain sensation, increasing risk of injury.

5. Recommend cessation of smoking.

Rationale: Vascular constriction associated with smoking and diabetes impairs peripheral circulation.

6. Discuss complications of disease that result from vascular changes: ulceration, gangrene, and muscle or bony structure changes.

Rationale: Although proper control of diabetes mellitus may not prevent complications, severity of effects may be minimized. Diabetic foot complications are the leading cause of nontraumatic lower extremity amputations. Note: Skin dry, cracked, scaly; feet cool; and pain when walking a distance suggest mild to moderate vascular disease (autonomic neuropathy) that can limit response to infection, impair wound healing, and increase risk of bony deformities.

7. Review proper foot care as outlined in teaching plan.

Rationale: Altered perfusion of lower extremities may lead to serious or persistent complications at the cellular level.