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NCP - Altered Tissue Perfusion

The patient, Marivic Cueson, presented with dengue hemorrhagic fever symptoms including a rash all over her body and low platelet count. The nurse diagnosed ineffective tissue perfusion related to anemia from DHF. Nursing interventions included monitoring vitals, assessing the patient's condition, administering medications, and encouraging rest to improve circulation. After 4 hours, the goals of lessening petechiae and preventing further bleeding were met.

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Leigh Kristel Andrion
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2K views

NCP - Altered Tissue Perfusion

The patient, Marivic Cueson, presented with dengue hemorrhagic fever symptoms including a rash all over her body and low platelet count. The nurse diagnosed ineffective tissue perfusion related to anemia from DHF. Nursing interventions included monitoring vitals, assessing the patient's condition, administering medications, and encouraging rest to improve circulation. After 4 hours, the goals of lessening petechiae and preventing further bleeding were met.

Uploaded by

Leigh Kristel Andrion
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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LEIGH KRISTEL A.

ANDRION CA9 DENGUE HEMMORHAGIC FEVER

PATIENTS NAME: CUYSON MARIVIC CUES SUBJECTIVE: Nagkaparashes ang buo kong katawan lalo na sa my tiyan, dun madami, as verbalized by the patient. OBJECTIVE: -presence of petechiae in the arms, abdomen and chest -WBC = 3000 -Platelet = 30, 000 -HgB = 10 -capillary refill 7 seconds V/S: T: 35.2 P: 58/min R: 20/min BP: 90/60 NURSING DIAGNOSIS Ineffective tissue perfusion related to decreased HgB concentration in the blood secondary to DHF RATIONALE OBJECTIVES NURSING INTERVENTION 1.Monitor Vital Signs 2. Assess patients condition 3.Note customary baseline data 4.Determine presence of dysrhythmias 5.Perform blanch test 6.check for Homans sign -lessened petechiae -absence of bleeding 7.Note presence of bleeding 8.Elevate HOB 9.Encourage quiet & restful atmosphere 10.Instruct to avoid tiring activities 11.Encourage light ambulation 12.Encourage use of relaxation techniques 13.Administer medications as prescribed RATIONALE EVALUATION

A decrease in Hgb caused by DHF which determines the cells carrying capacity for oxygen leads to altered circulation and perfusion

After 4 hours of nursing interventions, the patient will demonstrate behaviours to improve circulation as manifested by:

1.To obtain baseline data 2.To assess contributing factors 3.For comparison with current findings 4.To identify alterations from normal 5.To identify / determine adequate perfusion 6.To determine presence of thrombus formation 7.To determine risk of anemia 8.To promote circulation 9.To promote comfort& decrease tissue O2demand 10.To decrease cardiac workload 11.To enhance venous return 12.To decrease tension and anxiety level 13.To treat underlying cause

After 4 hours of nursing interventions, the patient demonstrated behaviours to improve circulation as manifested by: -lessened petechiae -absence of bleeding Goal Met

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