Patients Name: P.S.

C Medical Diagnosis: End Stage Renal Disease secondary to DM Nephropathy, HPT II Nursing Diagnosis: Ineffective tissue perfusion related to decreased hemoglobin concentration in the blood. Short-term Goal: After the 8 hour shift, the patients blood pressure and pulse rate will decrease within normal limits. Long-term Goal: At the end of the hospitalization days, the patient will show signs of increased perfusion such as absence of edema, free of pain or discomfort and etc..

Assessment
Objective: > BP = 160/100 > PR = 88 > RR = 26 >pale conjunctiva >restlessness >body weakness >low Hgb count (69) > Anuria > elevated creatinine = 811.70 umol/L ( 70115umol/L normal value) > with mechanical ventilator

Nursing Problem
Ineffective tissue perfusion related to decreased hemoglobin concentration in the blood.

Scientific Reason
Chronic renal disease is a progressive loss in renal function over a period of months or years. Because of this disease the blood vessels, the kidney cannot adequately produce erythropoietin that leads to decrease in Hgb and Hct count, thus resulting to anemia. Because of this, the patient manifested pale palpebral conjunctiva and paleness. Then the oxygen being supplied in the body is not enough due to decrease production of RBC by the kidney which are responsible for the oxygenation of

Intervention
Independent: >Establish rapport >monitor and record VS >assess patient general condition > encourage quiet and restful atmosphere >encourage early ambulation once tolerated >Discourage sitting/standing for long periods, wearing constrictive clothing,

Rationale

Evaluation
Goal met. >The patients blood pressure and pulse rate decreased within normal limits.

> to gain trust and cooperation. > to have a baseline data > to have baseline data and note any abnormal findings. > to conserve energy and lower tissue oxygen demands. > to enhance venous return >to improve and facilitates good circulation

tissues thus leading to ineffective tissue perfusion. Reference:

crossing legs

>check for calf tenderness > elevate the head of the bed, 30-45 degrees especially at night >instruct to avoid strenuous activities >restrict sodium, fluid and fat intake as indicated > instruct patients SO about food rich in iron, >regulate IVF as ordered >promote adequate bed rest Dependent: >Administered medication (Brochodilator) as needed.

> may indicate thrombus formation > to increase gravitational blood flow. > to conserve energy >to decrease excess fluid volume > to help increase Hgb count. >to maintain hydration >to provide adequate wellness.

Pathophysiology By Bullock

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