Nanda Nursing Diagnosis

Nursing Care Plan for Syncope Nursing Diagnosis : Ineffective Tissue Perfusion Syncope is one of the causes of loss of consciousness that are found in the emergency room (ER). Syncope is a transient loss of consciousness with acute onset followed by a fall, and with spontaneous recovery and perfect without any intervention. Syncope is a symptom of a disease that must be sought etiology. Definition of syncope (according to the European Society of Cardiology: ESC), is a characteristic clinical symptoms with loss of consciousness sudden and temporary, and usually lead to falls. Relatively rapid onset and recovery occurs spontaneously. The loss of consciousness caused by cerebral hypoperfusion. Activities before syncope can provide clues about the cause of the symptoms. Syncope can occur at rest, with changes in posture, the power, after a workout, or with certain situations such as coughing, or standing for long. Syncope occurs within 2 minutes of standing shows orthostatic hypotension. T...

Nursing Diagnosis: Ineffective Tissue Perfusio n related to active bleeding characterized by decreased consciousness, bleeding. Objectives / Expected outcomes: There was no impairment of consciousness, good capillary refill, bleeding can be resolved Nursing Interventions Assess the cause of bleeding Assess skin color, hematoma, cyanosis Collaboration in the provision of adequate IVFD Collaboration in the provision of blood transfusion. Rational: By knowing the cause of bleeding it will assist in determining appropriate interventions for patients Provide information about the degree / adequacy of tissue perfusion and assist in determining appropriate intervention Maintain fluid and electrolyte balance and maximize contractility / cardiac output so that the circulation becomes inadequate Repair / menormalakan red blood cell count and enhance oxygen-carrying capacity to be adequate tissue perfusion. Source : http://careplannursing.blogspot.com/2012/03/3-nursing-diagnosis-interventions-for...

Nursing Diagnosis for Anemia: Ineffective Tissue Perfusion related to the decrease in the cellular components required for the delivery of oxygen / nutrients to the cells. Objectives: increased tissue perfusion. Expected outcomes are: - indicates inadequate perfusion, such as stable vital signs. Ineffective Tissue Perfusion Nursing Interventions for Anemia Independent 1. Monitor vital signs assess capillary refill, color of skin / mucous membranes, nail beds. Rational: provides information about the degree / adequacy of tissue perfusion and help determine the need for intervention. 2. Elevate head of bed as tolerated. Rational: increase lung expansion and maximize oxygenation for cellular needs. Note: if there is hypotension contraindicated. 3. Monitor respiratory effort; auscultation of breath sounds adventisius note sounds. Rational: dyspnea, gurgling menununjukkan heart problems due to strain the old heart / cardiac output increased compensation. 4. Investigate complaints of chest ...