NCP Thromboangiitis Obliterans - Nursing Diagnosis and Interventions

1. Acute Pain / Chronic Pain related to vasospasm / reperfusion disorders, ischemic / tissue damage.

Goal: Pain is reduced and tissue damage is not widespread.

Intervention:
  • Record the characteristics of pain and paresthesias.
  • Check the patient's vital signs.
  • Discuss with the patient, how and why the pain inflicted.
  • Help the patient identify trigger factor or situation example: smoking, exposure to cold and how to handle.
  • Encourage the use of stress management techniques, entertainment activities.
  • Soak the affected area in warm water.
  • Give the room a warm, draft-free air, for example ventilation, air-conditioning, keep doors closed as indicated.
  • Monitor drug effects and action.
  • Collaboration: the medications as indicated, prepare surgical intervention when necessary.

Rational:
  • Knowing the pain level.
  • To monitor the general state of the client.
  • That patients understand how to process pain.
  • That patients understand the factors that influence pain.
  • Used to divert the attention of the client.
  • Warm water will make the blood vessels will dilate and blood flow.
  • Avoid infection and keep the air hot.
  • Determine the level of effectiveness of the drug.
  • Administration of drugs to relieve pain.


2. Ineffective Tissue Perfusion is related to cessation of arterial blood flow

Intervention:
  • Observation of skin color on the sick.
  • Note the decrease in pulse.
  • Evaluation of pain sensation parts, for example: sharp / shallow, hot / cold.
  • View and examine the skin for ulceration, lesions, gangrene area.
  • Recommended for proper nutrition and vitamins.
  • Collaboration: the medications as indicated (vasodilator), example: drainage lesions for culture or sensitivity.

Rational:
  • To see cyanosis or redness of the skin.
  • Identify the severity of the cessation of arterial blood flow.
  • Knowing levels, flavors, and forms of pain.
  • Seeing how big a part that had gangrene.
  • Proper nutrition and vitamin requirements are complete will increase the body's immune system.
  • Giving obta vasodilator make the arteries dilate and blood flow.


3. Knowledge Deficit: the need to learn about the condition, treatment needs related to lack of knowledge / resources are not familiar with, wrong perception / misunderstood.

Intervention:
  • Provide information to patients about the disease.
  • Encourage clients to ask questions about the disease.
  • Instruct to avoid exposure to cold.
  • Preserve the environment at a temperature above 20.9 C eliminate cold flow.
  • Discuss the possibility of moving to a warmer climate.
  • Emphasize the importance of stopping smoking, provide information on local clinics / support group.
  • Help the patient to create a method to avoid or alter discuss stress relaxation techniques.
  • Emphasize the importance of viewing each day and do the right skin care.

Rational:
  • Increase patients' knowledge about the disease.
  • Knowing the client's level of curiosity about the disease.
  • Cold temperatures make the constriction of the blood vessels and will aggravate the blockage of blood flow.
  • Hot temperature makes blood vessels to maintain a state of dilatation.
  • Avoid the severity of which will happen.
  • That patients know and understand that smoking is a major contributing factor to the occurrence trombongitis.
  • Distraction and relaxation techniques to make the patient more calm in responding.
  • Avoid skin injury.

4. Anxiety related to the action procedure to be performed

Intervention:
  • Describe the action procedure to be performed.
  • Explain the importance of actions to be taken.
  • Observation of vital signs.
  • Give comfort to the patient.
  • Reassure the patient that the action to be performed is the best course of action.
  • Reassure the patient that the procedure acts to be performed safely.
  • Collaboration with physicians for the provision of drugs.
Rational:
  • Increase patients' knowledge about action procedure.
  • In order for patients to understand why the need for that action.
  • Knowing the general state of the client.
  • Patients will feel calm and do not worry with action procedures to be performed.
  • Reduce the level of anxiety on the client.
  • Reduce negarif thinking about an act procedures.
  • To create a calm and reduce anxiety levels.
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