Tissue perfusion alteration (renal) related to decreased cellular exchange flow Definition: Decrease in cellular nutrition and respiration

caused by decreased capillary blood flow Associated medical diagnoses: Acute: Acute renal failure Aortic aneurysm DIC Hemorrhage MI Renal Calculi Shock Sickle cell crisis Chronic: Chronic renal failure DM Nephrotoxic drug poisoning Polycystic kidney disease Assessment: Age Sex Health history, including surgery, any condition resulting in fluid volume depletion, or use of nephrotoxic drugs Renal status, including color of urine, intake and output, presence of anuria or oliguria, urine specific gravity, weight Cadiovascular status, including blood pressure, central venous pressure, presence of dependent edema, fluid retention, or palpitations Respiratory status, including auscultation of breath sounds, respiratory rate and rhythm, shortness of breath Neurologic status, including level of consciousness, mental status, orientation and evidence of decreased tolerance to activity, fatigue, weakness Integumentary status, including color, moisture and presence of edema and secondary ulcerations from edema Nutritional status, including thirst, signs of anorexia Laboratory studies, including BUN, creatinine, creatinine clearance, hemoglobin, serum electrolytes, urine osmolality Defining characteristics: Abnormal serum electrolytes levels Dark, concentrated urine Decreased hemoglobin levels Decreased LOC Decreased urine osmolality Decreased urine output Elevated BUN, creatinine and creatinine levels Increased blood pressure Peripheral edema Shortness of breath Weakness Weight gain Expected outcomes: Patient maintains fluid balance Patient maintains urine specific gravity within normal limits (specify) Patients weight does not fluctuate Patient reports increased comfort Patient maintains hemodynamic stability

Patient identifies risk factors that exacerbate decreased tissue perfusion and modifies lifestyle appropriately Patient communicates understanding of medical regimen, medications, diet, and activity restrictions Interventions and rationale

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Monitor and document patients intake and output every hour until output is greater than 30 ml/hour, then every 2 to 4 hours. If patient doesnt have history of renal disease, urine output is good indicator of tissue perfusion. Decreased or absent urine output usually indicates poor renal perfusion.

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Document patients urine color and characteristics. Report any changes. Concentrated urine may indicate poor kidney function or dehydration. Monitor and document patients weight daily (before breakfast). Weighing patient helps predict overall fluid status. Weight gain may indicate fluid overload. Weighing at regular times gives better indication of weight changes. Assess patient for presence of dependent edema. Dependent edema may indicate lack of kidney function. Observe patients voiding patterns to note deviations from normal. Monitor patients urine specific gravity, serum electrolytes, BUN, and creatinine. Rising levels may indicate decreased kidney function. Monitor patients hemodynamic status and vital signs. Notify doctor of any changes. An increase from baseline may indicate fluid overload caused by lack of kidney function. Explain reasons fro therapy and its intended effects to patient and family members to encourage patient to take an active role in health maintenance.

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Allow frequent rest periods to enable patient to conserve energy.

Refer patient to a dietitian for a special diet for renal impairment to help patient avoid foods increased demands on kidneys. Instruct patient to check with doctor before taking over-the-counter (OTC) medications. OTC medications may be nephrotoxic.

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Administer low-dose dopamine, as prescribed, to dilate patients renal arteries and encourage tissue perfusion. Provide patient and family members or partner with psychological support if renal failure is acute or chronic to encourage healthy adaptation. Documentation: Patients expressions of concern over symptoms of decreased tissue perfusion Vital signs, intake and output, LOC, and other clinical findings. Nursing interventions performed to maintain fluid balance and hemodynamic stability Patients response to nursing interventions Patients response to education Evaluations for each expected outcomes Definition: Decrease in oxygen resulting in the failure to nourish the tissues at the capillary level. [Although tissue perfusion problems can exist without decreased cardiac output, there may be a relationship between cardiac output and tissue perfusion.] RELATED FACTORS Hypervolemia; Hypovolemia; Interruption of flow; Decreased hemoglobin concentration in blood; Enzyme poisoning; Altered affinity of hemoglobin for oxygen; Impaired transport of oxygen; Mismatch of ventilation with blood flow; Exchange problems; Hypoventilation DEFINING CHARACTERISTICS Subjective: Cardiopulmonary Chest pain; Dyspnea; Sense of impending doom

GastrointestinalNausea; Abdominal pain or tenderness Peripheral Claudication Objective :Renal Altered blood pressure outside of acceptable parameters; Oliguria; Anuria; Hematuria; Elevation in BUN/creatine ratio Cerebral Altered mental status; Speech abnormalities; Behavioral changes; [Restlessness]; Changes in motor response; Extremity weakness; Paralysis; Changes in pupillary reactions; Difficulty in swallowing Cardiopulmonary Arrhythmias; Capillary refill >3 sec; Altered respiratory rate outside of acceptable parameters; Use of accessory muscles; Chest retraction; Nasal flaring; Bronchospasms; Abnormal arterial blood gases; [Hemoptysis] Gastrointestinal Hypoactive/absent bowel sounds; Abdominal distention; [Vomiting] Peripheral Altered skin characteristics (e.g., hair, nails, moisture); Skin temperature changes; Skin discolorations; Skin color pales on elevation, color does not return on lowering the leg; Altered sensations; Blood pressure changes in extremities; Weak/absent pulses; Diminished arterial pulsations; Bruits; Edema; Delayed healing; Positive Homans sign