NURSING CARE PLAN

Problem: Ineffective tissue Perfusion Date Identified: June 7, 3013 Cues: Received patient per stretcher with heplock at right arm, with oxygen via nasal prong, with respiratory rate of 36 cpm, restlessness noted. Patient is dyspneic as observed. With the laboratory results of the following: Result Hemoglobin Hematocrit Urea 53 0.17 146.65 Unit g/L L/L mg/dL Reference 120-160 0.37-0.47 7.00-18.68

Analysis of the problem: Hemoglobin in the blood carries oxygen from the respiratory organs such as lungs to the rest of the body (i.e. the tissues) where it releases the oxygen to burn nutrients to provide energy to power the functions of the body, and collects the resultant carbon dioxide to bring it back to the respiratory organs to be dispensed from the body. Decrease in hematocrit level may indicate acute blood loss or anemia. Increased in urea in the blood is an indicator of dehydration, pre-renal or renal failure. Therefore, decrease in hemoglobin and other components of our blood means decrease oxygen supply to other parts of the body. Increase urea in the blood and the dehydration of the body could lead to viscosity of the blood that makes blood flows slowly to other organs and tissues. Due to this, patient has difficulty breathing and restless. Statement of patients care objectives:

After nurse-patient interaction, patient will be able to: Demonstrates adequate tissue perfusion as evidenced by palpable peripheral pulses, warm and dry skin, adequate urinary output, and the absence of respiratory distress Verbalizes knowledge of treatment regimen, including appropriate exercise and medications and their actions and possible side effects Identifies changes in lifestyle that are needed to increase tissue perfusion.

Nursing Actions 1. Assessed patients status and vital signs taken. 2. Assisted patient to moderate high back rest. 3. Maintained on Oxygen theraphy @ 2Lpm 4. Encourage patient to have enough rest and sleep 5. Assisted patient for salbutamol nebulization as order

Rationale Basis for prioritizing patients need and nursing intervention to be given.

Evaluation

To promote circulation

To increase oxygen supply to the body and promote perfusion To conserve energy and to decrease tissue O2 demand

Patient was transported to renal unit for hemodialysis with the following vital signs of Temperature of 37.3, Pulse rate of 88, Blood pressure of 150/90 and Respiratory rate of 30 cpm.

Relaxes bronchial uterine and vascular smooth muscle by stimulatng beta 2 receptors, thus, helps inceasing oxygen supply to the body To determine hydration status of the patient and to watched for hypovolemic shock Restriction of protein limits BUN

6. Monitored intake and output of the patient 7. Advised patient to limit taking protein rich foods such as meat and egg 8. Kept client warm, and had client wear socks. Do not apply heat.

Clients with arterial insufficiency complain of being constantly cold; therefore keep extremities warm to maintain vasodilation and blood supply. Heat application can easily damage ischemic tissues Hemodialysis is used to achieve the extracorporeal removal of waste products such as creatinine and urea and free water from the blood when the kidneys are in a state of renal failure. Thus decreasing viscosity of the blood.

9. Scheduled patient for emergency hemodialysis as ordered.