Nursing Diagnosis for Heart Failure : Ineffective Tissue Perfusion related to decrease in cardiac output, tissue hypoxemia, acidosis and possible thrombus or embolism.
Definitions:
Decreased oxygen delivery, the failure to feed the tissue at the capillary level.
Defining characteristics:
Renal :
- Changes in blood pressure beyond the limits of the parameters.
- Hematuria.
- Oliguria / anuria.
- Elevation / decrease in BUN / creatinine ratio.
- Intestinal hypoactive or absent.
- Nausea.
- Abdominal distention.
- Abdominal pain or does not feel soft (tenderness).
- Edema.
- Positive Homan's sign.
- Changes in skin characteristics (hair, nails, water / moisture).
- The pulse is weak or non-existent.
- Discoloration of the skin.
- Changes in skin temperature.
- Changes in sensation.
- Bluish.
- Changes in blood pressure in the extremities.
- Bruit.
- Too late to recover.
- Reduced arterial pulsation.
- Pale skin color in elevation, the color does not return to the decrease in the foot.
Cerebral:
- Abnormalities talk.
- Limb weakness or paralysis.
- Changes in mental status.
- Changes in the motor response.
- Changes in pupil reaction.
- Difficulty in swallowing.
- Changes in habits.
- Changes in the frequency of respiration beyond the limits of the parameters.
- The use of additional respiratory muscles.
- Turn over three second capillary (capillary refill).
- Abnormal arterial blood gases.
- The feeling of "impending Doom" (Fate threatened).
- Bronchospasm.
- Dyspnea.
- Arrhythmias.
- Nose redness.
- Chest retraction.
- Chest pain.
Related Factors :
- Hypovolemia.
- Hypervolaemia.
- Arterial flow was interrupted.
- Exchange problems.
- Venous flow is cut off.
- Hypoventilation.
- Mechanical reduction in venous or arterial blood flow.
- Damage to transport oxygen through the alveolar and capillary membranes.
- Not comparable between ventilation with blood flow.
- Poisoning enzyme.
- Changes in affinity / binding O2 with Hb.
- The decline in Hb concentration in the blood.
NOC:
- Circulation status.
- Tissue Perfusion: cerebral.
a. Demonstrating circulation status, which is characterized by:
- Systole and diastole the pressure within the expected range.
- No orthostatic hypertension.
- No signs of increased intracranial pressure (no more than 15 mm Hg).
- Communicate clearly and in accordance with ability.
- Shows attention, concentration and orientation.
- Process the information.
- Making the correct decision.
NIC:
Peripheral Sensation Management.
- Monitor the presence of certain areas only sensitive to heat / cold / sharp / blunt.
- Monitor the presence of paresthesia.
- Instruct family to observe the skin, if there are lesions or lacerations.
- Use gloves for protection.
- Limit movement of the head, neck and back.
- Monitor the ability of defecation.
- Collaboration of analgesic.
- Monitor the presence of thrombophlebitis.
- Discuss about the causes of changes in sensation.
