Nursing Problem: Impaired Tissue Perfusion Nursing Diagnosis: Impaired tissue perfusion related to decrease hemoglobin concentration in the

blood as manifested by low RBC count of 3.82, low hemoglobin count of 107, decrease paO2 level of 72.2, cyanosis and coolness of distal extremities, capillary refill of 4 seconds, dyspnea and restlessness. Nursing Goal: After 4 hours of rendering series of nursing interventions, the client will be able to demonstrate increased perfusion as will be manifested by normal RBC and hemoglobin count, normal paO2 level, normal skin color and normal temperature of distal extremities, capillary refill of 2 seconds, absence of dyspnea and absence of restlessness Nursing Interventions: Nursing Intervention/Responsibility

Rationale

Independent 1. Determine vital signs/hemodynamic Provide baseline data for comparison to follow parameters including cognitive status trends and evaluate response to interventions 2. Keep client semi Fowlers position and To decrease oxygen consumption and raise legs 20-30 degrees promotes lung expansion 3. Provide a quiet environment To promote adequate rest because stimuli and stress stimulate catecholamines and increases oxygen consumption 4. Provide psychological support by Honesty can be reassuring when so much maintaining a calm attitude, but admit activity and worry are apparent concerns if questioned 5. Provide adequate rest and positioning To achieve maximum comfort 6. Encourage relaxation techniques To reduce anxiety 7. Elevate legs when in sitting position To enhance venous return 8. Advise to move slowly, dangling legs To prevent orthostatic hypotension before standing 9. Elevate edematous legs and avoid To enhance venous return and restrictive restrictive clothing clothing worsen edema 10. Give information about positive signs or To provide emotional support and improvement encouragement 11. Monitor for changes in sensorium May indicate poor cerebral perfusion and deterioration so it must be addressed immediately 12. Instruct to perform deep breathing Improves breathing and oxygen intake exercises 13. Provide frequent small meals Reduces pressure on diaphragm and enhances chest expansion Dependent 14. Administer high flow oxygen To increase oxygen available for cardiac function and tissue perfusion 15. Administer inotropics as prescribed Increases cardiac output by increasing cardiac contractility

16. Administer diuretics as prescribed 17. Administer stool softeners if necessary as prescribed 18. Provide law salt food

To decrease fluid in the vascular compartment thus decreasing the workload of the heart To limit valsalva effect To decrease salt concentration in the blood that attracts water and increases fluid in the vascular compartment

Nursing Goal: After 4 hours of rendering series of nursing interventions, the client was able to demonstrate increased perfusion as manifested by normal RBC and hemoglobin count, normal paO2 level, normal skin color and normal temperature of distal extremities, capillary refill of 2 seconds, absence of dyspnea and absence of restlessness.