00200 Risk Of Decreased Cardiac Tissue Perfusion

Domain 4: activity/rest
Class 4: cardiovascular/pulmonary responses
Diagnostic Code: 00200
Nanda label: Risk of decreased cardiac tissue perfusion
Diagnostic focus: tissue perfusion
Approved 2008 • Revised 2013, 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « risk of decreased cardiac tissue perfusion is defined as: susceptible to decreased heart circulation (coronary), which can compromise health.

Risk factors

  • Insufficient knowledge of modifiable factors
  • Inappropriate use of substances

Risk population

  • People with family history of cardiovascular disease

Associated problems

  • Cardiac plugging
  • Cardiovascular Surgery
  • Coronary artery spasm
  • Diabetes mellitus
  • C-reactive protein elevation
  • Hyperlipidemia
  • Hypertension
  • Hypovolemia
  • hypoxemia
  • Hypoxia
  • Pharmacological preparations

Suggestions of use

  • Risk of decreased cardiac tissue perfusion is a potential diagnosis. If it becomes a real problem, medical care is required.
  • The role of the nursing professional is to monitor and detect changes in the patient’s condition; Therefore, the label of a collaboration problem should be used as a possible complication of coronary arterial spasm: ineffective cardiac tissue perfusion.

Suggested alternative diagnostics

  • cardiac spending, decrease in

NOC Results

Note : The following results are used to measure the presence of decreased cardiac tissue perfusion:

  • Circulatory status: Unidirectional blood flow and without obstruction, with adequate pressure, through the large vessels of systemic and pulmonary circuits
  • Tissue perfusion: cardiac: sufficiency of blood flow of coronary vessels to maintain cardiac function

Note : The following results are related to risk factors for the decrease in cardiac tissue perfusion:

  • Behavior to the cessation of smoking: personal actions to stop consuming tobacco
  • Knowledge: Health behavior: Extension of knowledge about the promotion and protection of health
  • Knowledge: Diet: degree of understanding transmitted about the recommended diet
  • Knowledge: Diabetes management: level of understanding expressed about diabetes mellitus, its treatment and the prevention of its complications
  • Effectiveness of cardiac pumping: sufficiency of the blood volume expelled by the left ventricle to maintain the systemic perfusion pressure

Evaluation objectives and criteria

  • Demonstrates a satisfactory level of the effectiveness of cardiac pumping and cardiac tissue perfusion
  • Demonstrates circulatory state, as manifested by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or without deviation from the normal range):
    • PA02 and PAC02 (partial oxygen pressure or carbon dioxide in arterial blood)
    • Left and right carotid pulses, brachial, radial, femoral and systolic, diastolic ta, pulse pressure, average ta, central venous pressure and lung pressure in wedge
  • Demonstrates circulatory state, as manifested by the following indicators (specify from 1 to 5: severe, substantial, moderate, light or none):
    • Angina on chest
    • Anomalous respiratory sounds, neck veins or blows in large vessels
    • Extreme fatigue
    • Peripheral edema and ascites
  • NIC Interventions

    Note : Nursing interventions focus on the prevention of cardiac tissue perfusion decrease.

    • Support for smoking cessation: helps another person to stop smoking
    • Help to lose weight: facilitation of weight loss and/or body fat
    • Liquid management: Promotion of water balance and the prevention of complications resulting from abnormal or non -desirable concentrations of liquids
    • Oxygen therapy: Oxygen administration and efficiency control
    • Cardiac prevention: Prevention of an acute episode of deterioration of heart functioning by reducing myocardial oxygen consumption or the increase in myocardial oxygen supply
    • Promotion of the exercise: promotion of a regular physical activity to maintain or raise the level of health and physical form
    • Treatment of substance consumption: patient care and care and family members suffering from physical and psychosocial problems related to alcohol or drug use
    • Surveillance: Collection, interpretation and synthesis of patient data, continuous and with an end, to make clinical decisions
    • Surveillance of vital signs: Collection and analysis of cardiovascular and respiratory data, as well as body temperature, to determine and prevent complications

    Nursing Activities

    Valuations

    • Monitor chest pain (intensity, precipitating duration)
    • Observe changes from the ST segment in ECG
    • Monitor frequency and heart rhythm
    • Auscultate cardiac and pulmonary sounds
    • Monitor coagulation studies (prothrombin time or TP, part -time thromboplastin or TPT, and platelet count)
    • Weigh the patient every day
    • Monitor the electrolyte values ??associated with arrhythmias (for example, serum potassium and magnesium)
    • Perform a detailed evaluation of peripheral circulation (peripheral pulses, edema, capillary filling, skin coloration and temperature)
    • Monitor income and expenses
    • Monitor peripheral pulses and edema
    • (NIC) Cardiac prevention:
      • Identify the patient’s arrangement to make modifications to his lifestyle
      • Identify the methods that the patient uses to handle stress

    Patient and family education

    • Instruct the patient to avoid Valsalva’s maneuver (for example, not to effort during intestinal movements)
    • Explain restrictions on caffeine, sodium, cholesterol and fat intake
    • Explain the reasons why you should ingest foods frequently and in small amounts

    Collaboration activities

    • Administer medications according to prescription or protocols (analgesics, anticoagulants, nitroglycerin, vasodilators, diuretics and positive inotropic medications and for contractility)

    Others

    • Ensure the patient and family that lights and call bells will be treated promptly
    • Promote rest (for example, limit visits, control environmental stimuli)
    • Apply compression therapy, as required (such as anti -manbolic stockings, sequential compression system)