View Record Details Media by Jesse Christopherson
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Nursing Diagnosis INEFFECTIVE TISSUE PERFUSION NDx Decreased cardiac output associated with: Impaired relaxation and contractility of the heart associated with stiffening of the ventricular walls Increased cardiac workload resulting from an increase in vascular resistance, thickened and rigid cardiac valves, and stress of current illness Increased vascular resistance associated with decreased elasticity and increased rigidity of the arterial vessels associated with changes in the proportion of elastin and collagen in the vessel walls and accumulation of substances such as calcium and lipids Decrease in baroreceptor sensitivity Peripheral pooling of blood associated with loss of muscle tone in extremities, decreased competency of venous valves, and venous dilation (results from loss of vascular elasticity) DESIRED OUTCOMES: The client will maintain adequate tissue perfusion as evidenced by: Nursing Diagnosis IMPAIRED RESPIRATORY FUNCTION * Ineffective breathing pattern ( NDx ) Loss of alveolar elasticity (results in reduced efficiency of air expulsion) Decreased chest expansion associated with calcification of costal cartilage and weakened respiratory muscles Decreased responsiveness of chemoreceptors to hypoxia and hypercapnia Ineffective airway clearance ( NDx ) Related to stasis of secretions associated with decreased activity during illness and an age-related decrease in ciliary activity and cough effectiveness Loss of effective lung surface associated with a reduced number of alveoli, changes in the alveolar walls, and accumulation of secretions in the bronchioles and alveoli (can result from ineffective airway clearance) Reduced airflow associated with loss of alveolar elasticity, restricted chest expansion, and premature closure of small airways Decreased pulmonary blood flow associated with a decrease in the number of capillaries surrounding the alveoli, fibrosis of the pulmonary vessels, and a generalized decrease in tissue perfusion Nursing Diagnosis RISK FOR DEFICIENT FLUID VOLUME NDx Age-related decrease in total body water Decreased fluid intake associated with: Age-related decline in kidneys ability to conserve water when a deficit is caused by disease or environmental factors DESIRED OUTCOMES: The client will not experience deficient fluid volume as evidenced by: Nursing Diagnosis IMBALANCED NUTRITION: LESS THAN BODYREQUIREMENTS NDx Definition: Intake of nutrients insufficient to meet metabolic needs Decreased oral intake associated with: Anorexia resulting from factors such as depression, loneliness, diminished sense of smell and/or taste, early satiety, and dyspepsia Difficulty chewing and swallowing food resulting from poor dentition, a decreased amount of saliva, and weakened chewing and swallowing muscles Decreased ability to purchase and/or prepare healthy foods Decreased utilization of nutrients associated with impaired digestion resulting from: Decreased ability to chew foods thoroughly Reduced secretion of digestive enzymes (e.g., salivary ptyalin, hydrochloric acid, pepsin, lipase) Reduced absorption of nutrients associated with hypochlorhydria, decreased intestinal blood flow, and atrophy of the absorptive surface of the intestine Nursing Diagnosis IMPAIRED COMFORT NDx (DYSPEPSIA, GASTRIC FULLNESS, AND/OR GAS PAIN) Increased gastroesophageal sensitivity to irritants associated with thinning of the esophageal and gastric mucosa Gastroesophageal reflux associated with decreased tone of the lower esophageal sphincter Impaired digestion of many foods associated with reduced secretion of digestive enzymes (e.g., hydrochloric acid, pepsin, lipase) Delayed esophageal and gastric emptying associated with decreased gastroesophageal motility Accumulation of intestinal gas associated with decreased peristalsis Nursing Diagnosis DISTURBED SENSORY PERCEPTION NDx Visual Related to: the lens becoming more opaque, losing elasticity, and yellowing
