Ineffective peripheral tissue perfusion:

1. Check for pallor, cyanosis, mottling, cool or clammy skin. Assess quality of every pulse.
2. Monitor for oxygen saturation
3. Assist with position changes.
4. Promote active/passive ROM exercises.
5. Provide oxygen therapy as necessary.
6. Position patient properly in a semi-Fowler’s to high-Fowler’s as tolerated.

Fluid volume excess:

1. Monitor input and output
2. Monitor fluid intake.
3. Monitor vital signs: noting BP, HR
4. Assess for bounding peripheral pulses
5. Assess for crackles in the lungs, changes in respiratory pattern, shortness of breath, and
orthopnea.
6. Note for presence of edema by palpating
7. Limit sodium intake as prescribed.
8. Elevate edematous extremities, and handle with care.
9. Aid with repositioning every 2 hours if the patient is not mobile.
10. Instruct patient, caregiver, and family members regarding fluid restrictions, as appropriate.