Analysis Nursing Diagnosis Ineffective Peripheral Tissue Perfusion Related to Compromised blood flow Secondary to Diabetes Mellitus and

Chronic Renal Failure

Priority

Client Goal Goal: 2/20/11 Client will have improved peripheral tissue perfusion.

Planning and Implementation Nursing Orders (NO) Nurse will: 1. Teach patient ROM for 15 minutes at 1000 once a day and encourage client to do ROM twice a day at 1230 and 1630.

Rationale Give references to each NO

1. The patient is encouraged to remain
active and is ambulated whenever possible. Active and passive exercise increase muscular, skin, and vascular tone. Smeltzer, et. Al. 2010. P. 189 2. Activity, exercise, and repositioning improve tissue perfusion. In patients who have evidence of compromised peripheral circulation, positioning and elevation of the body parts promotes venous return and diminish congestion. Smeltzer, et. Al. 2010 p.189 3. A high protein diet with protein supplements may be helpful. Iron preparations may be necessary to raise the hemoglobin concentration so that tissue oxygen levels can be maintained within acceptable limits. Smeltzer, et. Al. 2010 p.189

AMB (signs & symptoms)

AEB Patient will EO1 improve to warmth to touch to feet. EO2 Pedal blood pressure will improve to 34 mmHg on left foot and stay at 52 mmHg on right foot. EO3 RBC > 4 HGB > 12 HCT > 35

Client
1. Feet cold to touch.

2. Reposition client every 2 hours even hours from elevating feet with pillow to dangling feet on side of bed while doing lower extremity ROM.

2. Pedal blood pressure is 30 mmHg on left foot and 52 mm Hg on right foot.

3. RBC 3.52 HGB 10 HCT 31.1

3. Teach client for 5 minutes twice a day at 1130 and 1630 the importance of high protein and iron intake and hydration for diet. Encourage 4-5 L of clear liquids each day if not contraindicated. Monitor I & O s and weight daily. 4. Assess blood pressure, H&H, allergies. Administer 5000 unites of epoetin (Procrit) IV daily at 0900 as doctor prescribed. Monitor for chest pain, heavy feeling, pain spreading to the arm and shoulder, SOB, slurred speech, problems with vision and balance. Assess lab results RBC and H&H. Document.

4. Procrit is used to stimulate the production of red blood cells and is given for anemia which is a complication of chronic renal failure. Monitor H&H and blood pressure. ATI, et. Al. 2010 p.785

2/22/11 2030

2/22/11 2030

Not met because client¶s feet are cold to touch. EO1: Continue because patient¶s skin is still cold to touch on feet. Goal: Continue because patient¶s needs improved tissue perfusion for healing of necrotic toe. HCT 33. EO3 Continue because RBC 3. NO3: Keep to promote wound healing and circulation through hydration. HGB < 12.Evaluation Date of evaluation: 2/22/11 Goal not met EO1. EO2: Continue because patient¶s left foot BP is at 30 mmHg and not above 34 mmHg. (Chronic renal failure and Diabetes Mellitus). NO2: Keep to improve circulation and prevent pressure ulcers.4. NO4: Keep as DR. Nursing diagnosis: Continue because patient¶s peripheral tissue perfusion has not improved. deletion or continuation *New data: Patient is on activity restrictions to bedside commode only due to necrotic toe. HGB 11. Not met because pedal B/P on left foot is 30 mmHg. EO3. Nursing Orders (NO) NO1: Keep to improve circulation and tissue perfusion while in bed. HCT < 35. . prescribed to prevent anemia which is a common complication in perfusion problems.83. Reassessment Reassess the entire plan of care and give rationale for addition. D/C intervention: Patient will continue ROM after discharge as well as increased activity with physical therapist. EO2. Not met because RBC < 4.

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