Patient maintains optimal tissue perfusion to vital organs, as evidenced by strong peripheral pulses, normal ABGs, alert LOC, and absence of chest pain.
Cellulitis What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?
This care plan is listed to give an example of how a Nurse LPN or RN may plan to treat a patient with those conditions. Do not treat a patient based on this care plan. Care Plans are often developed in different formats. Some hospitals may have the information displayed in digital format, or use pre-made templates.
The most important part of the care plan is the content, as that is the foundation on which you will base your care. Nursing Care Plan for: Cellulitis If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below.
Otherwise, scroll down to view this completed care plan.
A 70 year old male presents to you floor. He was admitted to you from the ER. The patient is alert and oriented times four. He lives alone at home and has a home health nurse that visits him 2 times a week. The patient states he noticed that his right and left legs have started to become extremely red, warm to the touch, and tender when he touches them.
The patient winces in pain as your palpate the area. You note as well that the patients feet are cool to the touch and you are unable to palpate a pulse. The patient history includes: This test came back as negative.
Blood cultures are pending at this time.
The patient is started on IV antibiotics. He also states that they have started to swell. He reports having pain while walking. You use a Doppler to find the dorsalis pedis and post tibial pulses which you document as faint in both the right and left feet.
An ultrasound was performed on the lower extremities to rule out a deep vein thrombosis in the right and left legs.Ineffective Tissue Perfusion: Decrease in oxygen, resulting in failure to nourish tissues at capillary level. Blood is a connective tissue comprised of a liquid extracellular matrix termed as blood plasma which dissolves and suspends multiple cells and cell fragments.
Jul 22, · I would be supportive on all your articles and blogs as a result of they are simply up to the metin2sell.com Apr 19, · Not enough information to come up with a proper nursing diagnosis and there is definitely more than one. I’m assuming you mean the priority nursing diagnosis, in which case you would need to know what is causing the hypotension.
Nanda Nursing Diagnosis. Impaired Gas Exchange related to decreased volumes and lung compliance, pulmonary perfusion and alveolar ventilation. Goal: Signs and symptoms of respiratory disstres, deviation of the function and the risk of infant respiratory distress syndrome can be identified.
Impaired Tissue Integrity: Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues. Sep 24, · NCP for Ineffective Tissue Perfusion - related to a decrease in the cellular components required for the delivery of oxygen / nutrients to the cells. Characterized by: Capillary refill time (CRT) is more than 3 seconds, cyanosis, pale skin, dry mucous membranes, nails and hair brittle.