ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

SUBJECTIVE: Ineffective Tissue At the end of the shift, INDEPENDENT: RATIONALE: Goal met. At the end
(entubated) Perfusion secondary to the patient will maintain of the shift, the
disease process optimal tissue perfusion - Monitor quality of all Assessment is needed for patient maintained
OBJECTIVE: (Chronic Kidney to vital organs, as pulses. ongoing comparisons; optimal tissue
- Lethargy Disease) as manifested evidenced by strong loss of peripheral pulses perfusion to vital
- Elevated by elevated blood peripheral pulses, alert must be reported or organs, as evidenced
BUN/creatinine pressure LOC, and the reduction treated immediately. by strong peripheral
ratio (22mg/dl: of Blood pressure from pulses, alert LOC, and
1.5mg/dl) 160/60 to 140/60 - Maintain optimal This ensures adequate the reduction of Blood
- Decreased Urine mmHg. cardiac output. perfusion of vital organs. pressure from 160/60
Output (<30 ml prevent or minimize Support may be required to 140/60 mmHg.
/hr) unpleasant odor or to facilitate peripheral
- Mottling skin sights circulation (e.g.,
- Peripheral edema elevation of affected
- Vital signs as limb, antiembolism
follows: devices).
CR of 86 bpm
BP of 160/60 - Do passive range-of- Exercise prevents venous
mmHg motion (ROM) stasis.
RR of 24 cpm exercises to unaffected
extremity every 2 to 4
hours.

- Keep cannulated Movement may cause

extremity still. Use soft trauma to artery.
restraints or arm
boards as needed.

- Administer oxygen as This saturates circulating

needed. hemoglobin and
increases the
effectiveness of blood
that is reaching the
ischemic tissues.

BAUTISTA, Jesther Rowen, SN IV

 - Position properly. This promotes optimal
lung ventilation and
perfusion. The patient
will experience optimal
lung expansion in upright
position.
DEPENDENT:

- Administer Lowers blood pressure by

antihypertensive as selectively stimulating
ordered. receptors in the brain
that monitor
catecholamine levels in
the blood. These
receptors close a
feedback loop that
begins with descending
sympathetic nerves from
the brain that control the
production of
catecholamines
(epinephrine, also known
as adrenaline, and
norepinephrine) in the
adrenal medulla.

BAUTISTA, Jesther Rowen, SN IV