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NURSING EXPLANATION OBJECTIVES DIAGNOSIS/CUES OF THE PROBLEM

Ineffective renal tissue perfusion r/t interruption of blood flow S> Nahihilo ako tapos nanghihina hindi ako makabangon O> with initial vital signs of BP= 110/70mmHg P=78bpm RR=20cpm T=36.7C >alert, conscious, coherent >full and equal peripheral pulses >pink nailbeds >lips of natural pale color >capillary refill of more than 3 sec >skin turgor does not go back immediately >dry oral mucous membranes >no signs of edema >hypoactive bowel sounds of 3bpm heard >intact abdominal binder >with IFC attached to LTO> After 3 days of nursing interventions, the patient will demonstrate improved tissue perfusion as evidenced by the following: a. Stabilized vital signs b. Strong peripheral pulses c. Adequate urine output d. Absence of edema e. Usual mentation f. Good capillary refill g. Absence of paresthesias h. Be free of thrombus formation STO> After 3 days of nursing interventions, the patient will be able

INTERVENTIONS

RATIONALE

EVALUATION

Dx: 1. Monitor vital signs >To obtain baseline vital signs and to be able to identify changes which needs immediate interventions >To assess if the kidneys have returned to its normal functioning after the anesthesia has wear off >changes may reflect diminished perfusion to the central nervous system due to ischemia or infarction >To provide baseline data >Vital signs are as follows: BP= 110/80 PR=70 RR=18cpm T= 36.6C

2. Measure urine output per hour and note characteristic

>Urine output ranges from 1020cc per hour characterized as light yellow in color >Patient is alert, conscious and coherent with no signs of decreasing mentation

3. Note level of consciousness

4. Review laboratory tests

>Hemoglobin count is within normal range (114 mg/dL)

Tx:

hospi care bag draining 20cc per hour characterized as yellowish in color >Hemoglobin count of 114mg/dL

to empty bladder regularly and completely

1. Avoid pressure under the knees or crossing of legs

>Creates vascular stasis by increasing pelvic congestion and pooling of blood in the extremities, potentiating risk for thrombus formation >Movement enhances circulation and prevents stasis complications >Prevents stasis of secretions and respiratory complications

>Patient is on supine position with head elevated at 10 degrees

2. Assist with foot and leg exercises and ambulation as soon as possible 3. Turn patient and assist in coughing and deep breathing exercises 4. Maintain patency of IFC

>Patient is able to ambulate after 1 day of surgery

>Patient is able to do deep breathing and coughing exercises with no difficulty >Urine is draining well from IFC with no signs of infection

>Promotes free drainage of urine, reducing risk of urinary stasis/retention and infection >Promotes cleanliness, reducing risk of UTI

5. Provide good perineal cleansing

>Patient is able to do perineal care with the help of

significant other Edx: 1. Encourage wearing loosefitting clothing >Reduces pressure on compromised tissues, which may improve circulation and healing >To decrease tension level >Patient is wearing abdominal binder and over it is her hospital gown

2. Encourage use of relaxation activities such as guided imagery 3. Discourage massaging calf in presence of varicose veins

>Patient can do guided imagery

>To prevent embolization

>Health teaching on preventing thrombophlebitis after surgery according to level of understanding >Health teaching on the importance of proper nutrition post-surgery according to level of understanding

4. Encourage nutrition of high protein and high caloric intake

>To promote tissue healing

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