Subjective:

> easy fatigability

> pt. reports of a decrease in physical activity after her Tenkoff catheter insertion (from regular
ambulation to just sitting/standing and minimal ambulation w/ assistance in going to the
bathroom)

Objective:
> capillary refill time 4 seconds in fingernails and 5 seconds toenails
> radial and dorsalis pedis pulses with a grade of +1/+4
> extremities appear more pale and cooler than the rest of the body

Assessement:
Ineffective tissue perfusion: peripheral r/t mechanical reduction of peripheral blood flow
secondary to decreased physical activity.
Planning:
After 2 hours of nursing intervention, pt.’s peripheral circulation will improve as evidenced by:
a. increase in peripheral pulse grade
b. decrease in capillary refill time
c. improvement in the color and temperature of extremities
d. general increase in activity tolerance

Implementation:
>Instructed to perform ADLs independently without assistance whenever possible.
>Demonstrated how to perform active ROM exercises and assist pt. as needed. Increase the intensity and
duration of each set of exercises as tolerated:
a. head and neck
b. arms and hands
c. legs, knees and feet
>Assisted in adopting a plan to integrate independent ADL performance and ROM exercises in her daily
routine.
> Provided arm, hand, leg and feet massage.
> Kept pt.’s feet warm by putting on socks or use a blanket.

Evaluation:
After 2 hours, peripheral circulation has improved as evidenced by:
a. increase in radial and dorsalis pedis pulse grade (from +1/+4 to +2/+4)
b. decrease in capillary refill time in extremities ( from > 3 seconds to < 3 seconds)
c. improvement of color and temperature of skin in extremities (from pale-looking and cool to pinkish and
warm)
d. verbalization of an increase in activity tolerance and independent performance of ADLs
S: >
O:
nasal flaring
use of accessory muscle to breath
shallow breathing
abdominal enlargement due to the presence of ascites
abdominal girth is 44 inches
with tenkhoff catheter on peritoneal cavity
with cutdown catheter on ® basilic vein
A:
Ineffective breathing pattern r/t increased pressure in the diaphragm 2°
accumulation of fluid in the peritoneal cavity
P: Within 3hrs of proper nursing interventions the client breathing pattern will be
improve
I:
kept the head of bed in elevated position
assisted patient in a comfortable position
demonstrated to patient how to do deep breathing exercises
instructed to restrict or decrease fluid intake and maintain low fat and low salt diet
assisted patient in draining ascitic fluid.
E: After 3hrs of proper nursing intervention clients breathing pattern has been
improved as manifested by non-shallow breathing, no use of accessory muscle,
and no episodes of nasal flaring during respiration