Arcega, Romar Rico H.

BSN-III
NCP
Assessment Diagnosis Planning Implementation Rationale Evaluation
Namamanas ang paa ko ”as Ineffective Tissue Perfusion After 8 hours of nursing >Explain the need to use >These aids help promote After a series of nursing
verbalized by the patients' interventions, the antiembolic stockings or venous return and minimize intervention, the goal was
(+)irritability patient’s will demonstrate bandages, as ordered. fluid accumulation in the met.
(+)dry lips improved circulation of >Record intake if patient is extremities.
(+)facial grimace connotes affected extremity as on fluid restriction. >Patients should be reminded  Client's response to
pain evidenced by palpable and >Assess weight in relation to to include items that are intervention,
(+)pallor equal peripheral pulses, nutritional status. liquid teaching and
(+)anorexia reduced edema. >Note for presence of edema >Poor nutrition and actions performed
(+)hypervolemia by palpating over the tibia, decreased appetite over time  Attainment or
(+)peripheral edema on both ankles, feet, and sacrum. result in a decrease in weight, progress toward
feet(bipedal) pitting +2. >Assess for crackles in the which may be accompanied desired outcomes
T-37.4 lungs, changes in respiratory by fluid retention even  Client will
RR-16 pattern, shortness of breath, though the net weight demonstrate
PR-70 and orthopnea. remains unchanged. improved
BP-110/80 >Assess for bounding > Edema is graded from trace circulation of
O2sat-97% peripheral pulses (indicating barely affected extremity
(G-2 T-1 P-0 A -0 L-1) >Review serum electrolytes, perceptible) to 4 (severe as evidenced by
urine osmolality, and urine edema). palpable and equal
specific gravity. >These signs are caused by peripheral pulses,
>Elevate edematous an accumulation of fluid in reduced edema.
extremities, and handle with the lungs.
care. >These assessment findings
>Instruct client to avoid are signs of fluid overload.
massaging or rubbing the >All are indicators of fluid
affected extremity. status and guide therapy.
>Elevation increases venous
return to the heart and, in
turn, decreases edema.
Edematous skin is more
susceptible to injury.
>Massaging the extremity
increases the risk of
dislodging the thrombus that
can turn into emboli.