St. Paul University Philippines
Tuguegarao City, Cagayan 3500
School of Nursing and Allied Health Sciences
COLLEGE OF NURSING
Second Semester, A.Y 2021-2022
Bachelor of Science in Nursing - Level III
NCM 112 CARE OF CLIENTS WITH PROBLEMS IN OXYGENATION, FLUID AND ELECTROLYTES INFECTIOUS,
INFLAMMATORY AND IMMUNOLOGIC RESPONSE, CELLULAR ABERRATIONS (ACUTE AND CHRONIC)
Name: Demetri Ivanivitch
Civil Status: Single
Age: 23 years old
Nationality:
Address: Belarus
Sex: M
NCP1
Cues
Nursing Diagnosis
Ineffective Tissue
Perfusion related to
Client
insufficient blood
experiencing
flow/ Interruption in
increased shortness blood flow to organs
of breath and chills and tissues as
evidenced by
Client has been
changes in skin
intubated due to
color, temperature
deteriorated
and pulse pressure,
respiratory status
reduced BP
Subjective:
Background
knowledge
According to
NANDA, Ineffective
Tissue Perfusion
refers to the decrease
in oxygen resulting in
failure to nourish
tissues at capillary
level
Alterations in tissue
perfusion are
Goals and
Objectives
NOC: Tissue
Perfusion:
Peripheral,
Cardiopulmonary,
Renal
Goal: After the
nursing
interventions, the
client will be able to
achieve increased
Nursing Interventions
and Rationale
Evaluation
NIC: Vital Signs
Monitoring, Oxygen
Therapy, Fluid
Resuscitation,
Medication
Administration
GOAL MET
Objective:
23 years old
89 kg
Client was tested
positive in
COVID-19
Vital Signs:
BP: 78/40
HR:140 bpm
RR: 14 bpm
T: 38.6 C
O2 SAT: 81%
SPO2: 95%
FIO2: 50%
Urine output: <30
cc, Oliguria
Tachycardic
Peripheral/ Radio
Pulses (bilaterally):
weakened
bradycardia
(thread)
Skin: Cold and
clammy
sufficient to
contribute to systemic
inflammation.
Reduced cardiac
output and increased
venous pressure are
central to all
etiologies of heart
failure and result in
reduced end organ
blood flow. Failure to
augment blood flow
due to reduced
forward flow and
impaired vasodilation
leads to inadequate
skeletal muscle,
kidney, and liver
perfusion and
production of lactate,
a hallmark of tissue
ischemia. Similarly,
increased central
venous pressure not
only results in
microvascular
congestion and tissue
edema but also
reduced perfusion
pressure across
capillary beds. As a
consequence,
peripheral tissues
perfusion to vital
organs as evidenced
by normal Vital
signs,warm and dry
skin, present and
strong peripheral
pulses, balanced
Input and Output,
and normal ABGs.
Objectives:
After 7-8 hours of
nursing
interventions, the
client will be able to:
A. Achieve
adequate
cardiac tissue
perfusion .
The nurse will:
A1. Assess heart
sounds and pulses for
dysrhythmias. This can
be caused by
inadequate myocardial
or systemic tissue
perfusion.
A2. Monitor vital
signs, especially noting
blood pressure
changes. Changes in
blood pressure reflect
systemic vascular
resistance problems
that alter oxygen
consumption and
After 7-8 hours of
nursing interventions,
the client was able to:
A. Achieved
adequate
cardiac tissue
perfusion
through
adequate
oxygenation
administratio
n, mechanical
ventilation,
administering
fluids and
medications,
as evidenced
by vital signs
are in normal
Capillary Refill
(Nail beds and toe
nails) : 3 secs to
refill
Foot pulses: weak
and thready
Decreased platelet
count, elevated
lactate,
Hypoglycemia
receive inadequate
nutrient supply
including oxygen and
are either stressed,
reversibly injured, or
in more extreme
conditions undergo
apoptotic and/or
necrotic cell death.
Within ischemic
tissue beds, injured
and dying cells
trigger the activation
of immune cells
(monocytes,
macrophages,
dendritic cells, and
neutrophils) resulting
in the elaboration of
inflammatory
chemokines and
cytokines.
cardiac perfusion.
A3. Assess for
difficulty of breathing
or abnormal respiratory
rate. Indicators of
oxygen exchange
problems.
A4. Provide adequate
oxygenation as
indicated. Providing
supplemental oxygen
helps maintain oxygen
saturation greater than
90% and improve
cardiac and systemic
tissue perfusion.
A5. Assist intubation
and institution of
mechanical ventilation,
as indicated.
Development of or
impending respiratory
failure requires prompt
life- saving measures.
With severe
disturbances in gas
exchange, mechanical
ventilation is often
needed to assist the
respiratory system.
range:
BP: 100/70
HR:60-100
bpm
RR: 14 bpm
T: 37.3 C
O2 SAT: 95100%
SPO2: 95100%
(Kreit & Kellum,
2017).
A6. Anticipate
endotracheal closed
suctioning system. To
assist in secreting
pulmonary secretions.
Suctioning an
intubated patient with
COVID-19 is an
aerosol-generating
procedure and is
therefore at high rish
of spreading infection,
thus, a closed-suction
system is desirable and
adds extra protection.
(Vargas & Servillo,
2020)
A6. Elevate the head of
the patient for at least
30 degrees - 45 degrees
in semi- recumbent
position. The elevation
of the head of bed
(HOB) to a semirecumbent position (at
least 30 degrees) is
associated with a
decreased incidence of
aspiration and
ventilator-associated
pneumonia (VAP). The
intervention is
supported unanimously
by all four leading
guidelines, and newer
publications in the field
accept HOB elevation
as an effective, low-cost,
and low-risk
intervention (Agency for
Healthcare Research
and Quality)..
A7. Administer fluids
and electrolytes as
indicated to maintain
systemic circulation
and optimal cardiac
function.
A8. Administer
medications as
prescribed. To treat
underlying conditions
and help in
maintaining cardiac
tissue perfusion and
organ function.
B. Attain proper
renal
perfusion as
B1. Monitor Intake
and observe urine
Output, Urine color
B. Attained
proper renal
perfusion as
evidenced by
adequate
urine output.
and clarity.
Record urine specific
gravity as necessary.
A decrease in urine
output or change in
color and clarity could
indicate a
deterioration in renal
function. Hydration
status and renal
function are revealed
by specific gravity
measures.
evidenced by
1-2 ml/kg/hr
urine output ,
clear and Pale
yellow to
yellow urine
color.
B2. Monitor renal lab
values frequently.
Lab values such as
BUN and creatinine,
may help identify
changes in renal
function.
B3. Check for optimal
fluid balance.
Administer IV fluids as
ordered. Sufficient fluid
intake maintains
adequate filling
pressures needed for
tissue perfusion.
C. Demonstrate
C1. Monitor Vital
signs specifically
C. Demonstrated
Adequate
Peripheral
Perfusion.
Oxygen Saturation and
Pulse Rate and Check
ABG values. Low
levels of Hgb reduce
the uptake of oxygen at
the alveolar-capillary
membrane and oxygen
delivery to the tissues.
C2. Monitor color,
temperature, and
sensation of all
extremities.
Pallor, cyanosis, or
mottled skin color
indicate a blockage in
perfusion to the
extremity.
C3. Measure Capillary
refill to determine
adequacy of systemic
circulation.
-
C4. Palpate and
Monitor peripheral
pulses (radial, brachial,
femoral, popliteal,
dorsalis pedis, and
posterior tibia)
frequently. If not able
to find pulses, use
-
-
adequate
Peripheral
Perfusion
through
medication,
fluids,
electrolytes,
nutrients, and
oxygen
administratio
n, the patient
demonstrated
improved
peripheral
perfusion as
evidenced by:
Normal vital
signs:
SPO2= 96100%
PR= 60-100
bpm
Hgb= 13.216.6 g/dL
Capillary
refill <3
seconds
Normal skin
color and
temperature
Extremities
and a strong
and regular
Doppler. Pulses are
indicative of adequate
perfusion to the
respective body parts.
Absent or weak pulses
may indicate a
compromise in
perfusion.
peripheral
pulse. (60-80
bpm).
-
C5. Put soft linen or
padding on the bed.
This is to reduce the
pressure and maintain
good skin integrity.
Research evidence
shows that mattresses
made with higher
density (more
supportive) foam can
help prevent pressure
sores - also known as
bed sores - from
developing or
worsening.
C6. Administer fluids,
electrolytes, nutrients,
and oxygen as
indicated, to promote
optimal blood flow,
organ perfusion and
function.
-
Normal ABG
values:
pH : 7.35 to
7.45
PaO2: 10.7 to
13.3
kPa (80 - 100
mmHg)
PaCO2: 4.7 to
6.0
KPa (35 to 45
mm hg)
HCO3: 22 26 MMOL /
L
C7. Recommend or
Provide foot and ankle
exercises when client is
unable to ambulate
freely to reduce venous
pooling and increase
venous return.
C8. Review laboratory
studies such as lipid
profile, coagulation
studies,
hemoglobin/hematocrit
, diagnostic studies
(Doppler ultrasound,
venogram, leg
segmental arterial
pressure
measurements) to
determine probability,
location and degree of
impairment.
D. Show no
further
worsening/re
petition of
deficits.
D1. Emphasize the
necessity of routine
follow-up and
laboratory monitoring
for effective disease
management and
possible changes in the
therapeutic regimen.
D. Showed no
further
worsening of
deficits, as a
result of the
Compliance
of the patient
and
significant
others in
D2. Collaborate in
treating the underlying
disease (COVID-19
and MODS).
Treatment of the
underlying cause of
complication may
result in absence of
complication.
D3. As soon as the
patient is stable,
encourage the patient
to modify lifestyle
(avoiding crossed legs
at the knee when
sitting, changing
positions at frequent
intervals, rising slowly
from a supine/sitting to
standing position,
avoiding smoking).
These modifications in
lifestyle promote
adequate tissue
perfusion.
follow-up and
laboratory
monitoring,
collaboration
with
healthcare
professionals,
and lifestyle
modification.