Ineffective Tissue Perfusion R/T Impaired RAS Mechanism As Manifested by A High Blood Pressure Level

Ineffective Tissue Perfusion r/t impaired RAS mechanism as manifested by a high blood
pressure level
Independent Nursing Interventions:
 Asses skin color, temperature, moisture and whether changes are widespread or
localized.
- Helps in determining location and type of perfusion problem.
 Measure capillary refill.
- To determine adequacy of systemic circulation
 Determine pulse quality, as well as intensity.
- To evaluate distribution and quality of blood flow
 Note client’s nutritional and fluid status.
- Protein-energy malnutrition and weight loss make ischemic tissues more prone to
breakdown. Dehydration reduces blood volume and compromises peripheral
circulation.
 Assist with position changes.
- Gently repositioning patient from a supine to sitting/standing position can reduce
the risk for orthostatic BP changes.
 Position patient properly in a semi-Fowler’s as tolerated.
- Upright positioning promotes improved alveolar gas exchange.
 Promote active/passive ROM exercises.
- Exercise prevents venous stasis and further circulatory compromise.
 Provide a clean, safe and quiet environment.
 Diet restrictions of sodium.
 Discuss relevant risk factors.
- Information necessary for client to make informed choices about remediating risk
factors and committing to lifestyle changes.
 Review medication regimen and possible harmful side effects with client and SO.
Dependent Nursing Interventions:
 Administer medications such as antiplatelet agents, thrombolytics and antibiotics as

prescribed.
 Administer antihypertensive as prescribed.
-
 Administer fluids, electrolytes, nutrients, and oxygen as indicated.
- To promote optimal blood flow, organ perfusion and function. Oxygen saturates
circulating hemoglobin and augments the efficiency of blood that is reaching the
ischemic tissues.
Acute Pain related to immune process as manifested by a pain scale rate of 7/10
Independent Nursing Interventions:

 Assess the client’s pain level every 2 hours with the use of pain scale; Continualy assess
location, characteristics, onset, duration, frequency, quality and severity of pain.
- To fully understand client’s pain symptoms; to rule out worsening of underlying
condition/development of complications
 Provide rest periods to promote relief, sleep, and relaxation.
 Use non pharmacological pain relief methods (comfort measures, breathing exercise
and music therapy).
- The use of non-invasive pain relief measures that can increase the release of
endorphins; To distract attention and reduce tension
 Monitor for changes in general condition that may herald need for change in pain relief
method.
 Eliminate additional stressors or sources of discomfort whenever possible.
- Client may experience an exaggeration in pain or a decreased ability to tolerate
painful stimuli if environmental, intrapersonal, or intrapsychic factors are further
stressing them.
Dependent Nursing Interventions:

 Administer analgesics as prescribed by physician.
Medications:
Analgesic treatment
Narcotic analgesic is an Anti-inflammatory, analgesic, and antipyretic activities largely related to
inhibition of prostaglandin synthesis; exact mechanisms of action are not known. Inhibits both
cyclooxygenase (COX) 1 and 2. Ibuprofen is slightly more selective for COX-1.
Nursing interventions:
- Ensure that patient is well hydrated if using IV form.
- Administer drug with food or after meals if GI upset occurs.
- Arrange for periodic ophthalmologic examination during long-term therapy.
Antibiotic treatment
Penicillin or amoxicillin is the antibiotic of choice to treat group A strep pharyngitis. For
patients with a penicillin allergy, recommended regimens include narrow-spectrum
cephalosporins (cephalexin, cefadroxil), clindamycin, azithromycin, and clarithromycin.
Nursing interventions:
- Perform sensitivity test
- Ensure that patient receives full course as prescribed.
- Monitor disease progress and presenting signs and symptoms throughout course of drug
therapy.
- Provide the following patient teaching: safety precautions (e.g. avoiding hazardous tasks, ec.),
drinking lots of fluids and to maintain nutrition even though nausea and vomiting may occur,
report difficulty breathing, severe headache, fever, diarrhea, and signs of infection
Antihypertensive treatment
Antihypertensive drugs comprise several classes of compound with the therapeutic intention of
preventing, controlling, or treating hypertension. The classes of antihypertensive drug differ
both structurally and functionally.
Nursing Interventions:
- Assess blood pressure and pulse rate frequently.
- Check patient s/s for angioedema.
- Avoid given first dose at night due to increase hypotensive risk.

Ineffective Tissue Perfusion R/T Impaired RAS Mechanism As Manifested by A High Blood Pressure Level

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Ineffective Tissue Perfusion R/T Impaired RAS Mechanism As Manifested by A High Blood Pressure Level

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Ineffective Tissue Perfusion r/t impaired RAS mechanism as manifested by a high blood

Independent Nursing Interventions:

Dependent Nursing Interventions:

 Administer medications such as antiplatelet agents, thrombolytics and antibiotics as

Independent Nursing Interventions:

Dependent Nursing Interventions:

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