Nurse's Pocket Guide

ineffective TISSUE PERFUSION
• Check for calf tenderness (Homans’ sign), swelling, and redness,
which may indicate thrombus formation.
• Review diagnostic studies and laboratory tests (e.g., venogram,
angiography, clotting times, Hb/Hct).
• Observe for signs of shock/sepsis. Note presence of bleeding
or signs of DIC.
NURSING PRIORITY NO.3.To maximize tissue perfusion:
• Assist with treatment of underlying conditions (e.g., stent
placement, surgical reperfusion procedures, medications, fluid
replacement/rehydration, nutrients, treatment of sepsis, etc.),
as indicated, to improve tissue perfusion/organ function.
Renal
• Monitor vital signs.
• Measure urine output on a regular schedule. (Intake may be
calculated against output.)
• Weigh daily.
• Administer medications (e.g., anticoagulants in presence of
thrombosis, steroids in membranous nephropathy).
• Provide for diet restrictions, as indicated, while providing
adequate calories to meet the body’s needs. Restriction of
protein helps limit BUN.
• Provide psychological support for client/SO(s), especially
when progression of disease and resultant treatment (dialysis)
may be long term.
Cerebral
• Elevate HOB (e.g., 10 degrees) and maintain head/neck in
midline or neutral position to promote circulation/venous
drainage.
• Administer medications (e.g., antihypertensive agents,
steroids/diuretics [may be used to decrease edema], anticoagulants).
• Assist with/monitor hypothermia therapy, which may be
used to decrease metabolic and O2 needs.
• Prepare client for surgery, as indicated (e.g., carotid endarterectomy,
evacuation of hematoma/space-occupying lesion).
• Refer to ND decreased Intracranial Adaptive Capacity.
Cardiopulmonary
• Monitor vital signs, hemodynamics, heart sounds, and cardiac
rhythm.
• Encourage quiet, restful atmosphere. Conserves energy/
lowers tissue O2 demands.
• Caution client to avoid activities that increase cardiac workload
(e.g., straining at stool).
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
710 Cultural Collaborative Community/Home Care