COLLEGE OF NURSING

SILLIMAN UNIVERSITY
 CUES/EVIDENCES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Ineffective tissue perfusion At the end of our two-day  Monitor vital signs and laboratory  Serves as baseline data At the end of our two-day
related to decreased albumin care, the client will results and to determine for care, the client did not
 Verbalized that the concentration in the blood manifest increased tissue any abnormalities manifest increased tissue
edema on her left hand perfusion as evidenced perfusion as evidenced by:
and lower extremities by:
occurred when she has  Assess skin temperature, turgor,  To determine presence  Goal met. Vital signs are
regained consciousness  Vital signs within normal and integrity of edema or any within normal range
(date unable to recall) range abnormalities except blood pressure
after surgery as BP= 100-140/ 60-90
verbalized by the T= 36.5- 37.5◦C  Temperature: 36.7- 37C
husband P= 60-100bpm  Monitor IVF infusion rate, and the  To asses for  Pulse rate: 76- 80 bpm;
R= 15-20cpm IV site overinfusion/ strong and regular
 Verbalized feeling of underinfusion or any  Respiratory rate: 27
heaviness in the left other complications cpm, regular, quiet and
hand and lower effortless; taken twice
extremities  Blood pressure: 130/90
 Measure circumference of  Useful in identifying mmHg; taken twice
extremities, as indicated edema involved in the
Objective: extremities
 No presence of edema in  Goal partially met. Edema
 Presence of edema in the IV site and lower is still present in the
the IV site which is the extremities  Assess presence of neck  To determine for any lower extremities and in
left hand distention/ hepatojugular reflux other complications the IV site

 With 1 liter D5LR

running at 22gtts/min at  Skin temperature, turgor  Encourage early ambulation when  To increase peripheral  Goal not met. Skin
left arm and integrity are normal possible circulation temperature is still cooler
than the surrounding area
 Swollen area is cooler and tender to touch
than the surrounding  Discourage sitting or standing for  Enhances venous return
area a long period of time
 Balanced intake and  Goal met. output is
 Appears restless output (output> input) greater than intake:
 Elevate edematous extremities,  To reduce tissue Intake: 930 cc
 Fluid intake (IV): 520 cc change position frequently pressure and risk of Output: 1,200 cc
skin breakdown
 Fluid output: 727 cc

 Vital signs:
 Will demonstrate  Apply warm compress  To increase circulation  Goal met. used
 Temperature: 37.1 nonpharmacalogic of the affected area, nonpharmacalogic
C; taken twice methods and activities thus, reducing edema methods and activities to
 Pulse rate: 68-78 to improve circulation improve circulation such
bpm; strong and such as application of as application of warm
regular warm compress and  Encourage to eat food rich in  To help in the compress and ambulation
 Respiratory rate: ambulation and deep iron such as liver, and production of iron in and deep breathing
28 cpm, regular, breathing exercise vegetables the blood , thus exercise