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HDN NCP CASE PRES Ineffective Peripheral Tissue

Perfusion
Bachelor of Science Radiologic Technology (Medical Colleges of Northern Philippines)

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Nursing Care Plana

Assessment Nursing Intervention NCM 107/ NCM 104 Related Learning Experience
Planning Rationale Evaluation
Diagnosis (at least 10)
Subjective: Ineffective peripheral Short Term Goals Independent: Short Term Goals
“My baby started to tissue perfusion related to  Assessment
suck poorly, and his skin destruction of red blood After 6 to 8 hrs of After 6 to 8 hrs of
cells. nursing interventions  Monitor vital signs - To determine the need for nursing interventions
becomes yellow,” as intervention and the
verbalized by the the patient will be able the patient will be able
to: effectiveness of therapy to:
mother.
• Demonstrate increase  Assess skin for changes in - General indicators of • Demonstrate
Objective: circulatory status and
perfusion as evidence color, temperature and increase perfusion as
 Weak femoral by warm skin and moisture adequacy of perfusion. evidence by warm
pulses strong peripheral Edema formation can skin and strong
 Capillary refill pulses readily compress blood peripheral pulses
of 2-3 seconds vesssels there by
 Pale looking • Normalize body impeding circulation and • Normalize body
skin temperature within increasing temperature within
 Edema normal range of venousstasis/edema. normal range of
 Yellow coloring 36.5°C to 37.5°C 36.5°C to 37.5°C
of umbilical - Reduce peripheral
cord, skin, and Long Term Goals circulation often leads to Long Term Goals
the whites of  Assess extremities for skin
dermal changes and
eyes (jaundice) texture and edema
After 72-168 hrs of delayed healing After 72-168 hrs of
 Dark amber nursing intervention the nursing intervention the
urine patient will be able to: patient will be able to:
 Inadequate - Changes reflect
urine output  Assess skin for pallor, diminished circulation
less than 2 cyanosis, coolness, and/or hypoxia potentiating
• Maintain adequate • Maintain adequate
ml/kg/hour diaphoresis, and delayed capillary occlusion.
tissue perfusion and tissue perfusion and
 Ultrasound capillary refill.
lessen severity of lessen severity of
reveals jaundice as evidence jaundice as evidence
enlarged liver by decrease bilirubin - To assess for by decrease bilirubin
and spleen level in blood. compensatory level in blood.
 Laboratory  Assess respiratory rate, mechanisms of
results were: depth and quality vasodilation, as well as
- Low hgb level • be free of edema developing hypoxia, • be free of edema
10g/dL stress.
- Hematocrit • have adequate urine • have adequate urine
33% output measuring to output measuring to
- total bilirubin 2 ml/kg/hour 2 ml/kg/hour
of 46.1 mg/dL -Normal values adequate
- direct tissue perfusion. The most

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bilirubin of 1.1 significant decline in

mg/dL  Monitor laboratory studies bilirubin level occurs in
- BUN: 16 as indicated such as thefirst 4-6 hours after NCM 107/ NCM 104 Related Learning Experience
mg/dL, hematology, indirect and initiating photo therapy so
- creatinine 0.5 direct bilirubin. assess bilirubin
mg/dL, periodically
- a strong
positive result - Weigh infant twice a day,
(+++) on the note signs of dehydration
direct Coombs (e.g. reduce urine output,
test. dry and warm skin with
Vital signs:  Monitor fluid intake
poor turgor)
- BP: ranges and output.
from 70/50 to
- Hypoproteinemia in
80/60 mmHg
the newborn may
- CR: ranging
from 160-170 aggravate jaundice. One
 Evaluate maternal gram of albumin carries 16
bpm and prenatal mg of unconjugated
- RR: 60bpm nutritional bilirubin. Lack of sufficient
- °T: 38°C levels; note possible
albumin increases the
neonatal
amount of unbound
hypoproteinemia, es
pecially in preterm circulating (indirect)
infant. bilirubin, which may cross
the blood-brain barrier.

- Cold stress potentiates

release of fatty acids,
which compete for binding
 Keep infant warm sites on albumin, thereby
and dry; monitor increasing the level of
skin and freely circulating (unbound)
core temperature
bilirubin.
frequently.

- Excessive unconjugated
bilirubin (associated
with pathologic jaundice)
 Assess infant for has an affinity
for extravascular tissue,

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progression of signs including the basal ganglia

and behavioral of brain tissue. Behavior
changes: changes associated NCM 107/ NCM 104 Related Learning Experience
- Stage I involves with kernicterus usually
neuro-depression occur between the 3rd
(e.g., lethargy, and 10th days of life and
hypotonia, or
rarely occur prior to 36 hr
diminished/absent
of life.
reflexes).
- Stage II involves
neuro hyperreflexia
(e.g., twitching,
convulsions,
opisthotonos, or
fever).
- Stage III is mark
absence of clinical
manifestations.
- Stage IV involves
sequelae such as
cerebral palsy or
mental retardation

 Therapeutic

 Initiate phototherapy per - To allow for utilization

protocol, using fluorescent alternate pathways for
bulb place above the infant bilirubin excretion.
or bili blanket.

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 Perform hand hygiene

before and after every - To prevent transmission of NCM 107/ NCM 104 Related Learning Experience
procedure. microorganisms that could
add to current disease.

- To prevent eyes from

 Apply patches to closed
direct exposure to light and
eyes, inspect every 2 hours
prevent sterility of the
baby.
 Provide quiet and warm
environment - To promote comfort and
prevent irritability and to
lower tissue oxygen
demands.

 Provide and maintain room -This prevents

temperature and body vasoconstriction therefore
warmth without aids in maintaining
overheating. circulation and perfusion.

- if baby receiving
intravenous fluid or
 Educative
expressed breast milk,
 Encourage mother to breast increase the volume of the
fed at least every three fluid by 10% of total daily
hourly. volume per day as long as
the baby is under photo
therapy.

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NCM 107/ NCM 104 Related Learning Experience

- Breast milk interferes in
the conversion of indirect
bilirubin
 Educate the mother about
the effects of breast milk to
the baby

- Oxygen increase arterial

Dependent: saturation.

 Administer supplemental - It is normal human

oxygen as ordered immunoglobulin that has
been shown to reduce
 Transfused IVIG 1 vial 500
serum bilirubin level
mg ×3 hours using syringe
pump as ordered.
- Blood transfusion
increases the patients
 Assist with preparation and blood volume and raising
administration of exchange the hemoglobin level.
transfusion blood
component therapy (Blood
transfusion) as needed
- Maintains circulating
volume to maximize tissue
 Administer IV fluids as
order. Check for optimal perfusion.
fluid balance
- To maximize tissue
 Administer prescribed perfusion
medications with caution

Interdependent/ - to monitor for any

Collaborative progression or regression in
the disease process
 Collaborate with
the medical

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technologist in
monitoring several
blood tests. NCM 107/ NCM 104 Related Learning Experience

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