Signs and Symptoms: Increase in

serum creatinine, increase in blood

pressure and anuria

Ineffective Renal Tissue Perfusion related to

mechanical reduction of venous and/or arterial
blood flow(CAD)

Patient maintains maximum tissue

perfusion to kidneys as evidenced by
balanced I&O and absence of edema and
crackles in chest.
Nurse will assess for
signs of decreased Nurse will strictly
tissue perfusion (labs, monitor electrolyte
creatinine). balance such as
sodium intake

Nurse will monitor Nurse will consult

intake, observe provider on need for
changes in urine potential rescues such
output. as dialysis.

Nurse will
administer IV fluids
as ordered.
1: Assessment is the first step in planning management and
determining realistic goals because it provides baseline.

Evaluation: Doctor was consulted and patient 2: Reduced intake negatively affects perfusion and organ
function.
was put on fluid and sodium restriction, and
Lasix to diuerese. Head to toe assessment 3: Sufficient fluid intake maintains adequate cardiac filling
showed the crackles in the bases of his lungs pressures needed for tissue perfusion.

were gone, and no signs of edema were Health

4: This facilitates Assessment
perfusion when&it Communication
has gone down to the level
N211
present so goal was met. of ischemic damage.

5: Sodium and other electrolytes process through the kidneys.