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Y
Ineffective renal tissue LTO> After 3 days Dx:
perfusion r/t of nursing 1. Monitor vital >To obtain >Vital signs are
interruption of blood interventions, the signs baseline vital as follows: BP=
flow patient will signs and to be 110/80 PR=70
demonstrate able to identify RR=18cpm T=
S> ³Nahihilo ako tapos improved tissue changes which 36.6C
nanghihina hindi ako perfusion as needs immediate
makabangon´ evidenced by the interventions
following:
O> with initial vital signs a. Stabilized 2. Measure urine >To assess if the >Urine output
of BP= 110/70mmHg vital signs output per kidneys have ranges from 10-
P=78bpm RR=20cpm b. Strong hour and note returned to its 20cc per hour
T=36.7C peripheral characteristic normal characterized as
>alert, conscious, pulses functioning after light yellow in
coherent c. Adequate the anesthesia color
>full and equal urine output has wear off
peripheral pulses d. Absence of
>pink nailbeds edema 3. Note level of >changes may >Patient is alert,
>lips of natural pale e. Usual consciousness reflect conscious and
color mentation diminished coherent with no
>capillary refill of f. Good perfusion to the signs of
more than 3 sec capillary refill central nervous decreasing
>skin turgor does not g. Absence of system due to mentation
go back immediately paresthesias ischemia or
>dry oral mucous h. Be free of infarction
membranes thrombus
>no signs of edema formation 4. Review >To provide >Hemoglobin
>hypoactive bowel laboratory baseline data count is within
sounds of 3bpm heard STO> After 3 days tests normal range
>intact abdominal of nursing (114 mg/dL)
binder interventions, the
>with IFC attached to patient will be able Tx:
hospi care bag draining to empty bladder 1. Avoid pressure >Creates >Patient is on
20cc per hour regularly and under the vascular stasis supine position
characterized as completely knees or by increasing with head
yellowish in color crossing of pelvic congestion elevated at 10
>Hemoglobin count of legs and pooling of degrees
114mg/dL blood in the
extremities,
potentiating risk
for thrombus
formation

2. Assist with foot >Movement >Patient is able

and leg enhances to ambulate after
exercises and circulation and 1 day of surgery
ambulation as prevents stasis
soon as complications
possible

3. Turn patient >Prevents stasis >Patient is able

and assist in of secretions and to do deep
coughing and respiratory breathing and
deep breathing complications coughing
exercises exercises with no
difficulty

4. Maintain >Promotes free >Urine is

patency of IFC drainage of draining well
urine, reducing from IFC with no
risk of urinary signs of infection
stasis/retention
and infection

5. Provide good >Promotes >Patient is able

perineal cleanliness, to do perineal
cleansing reducing risk of care with the
UTI help of
 significant other

Edx:

1. Encourage >Reduces >Patient is

wearing loose- pressure on wearing
fitting clothing compromised abdominal binder
tissues, which and over it is her
may improve hospital gown
circulation and
healing

2. Encourage >To decrease >Patient can do

use of tension level guided imagery
relaxation
activities such
as guided
imagery

3. Discourage >To prevent >Health teaching

massaging calf embolization on preventing
in presence of thrombophlebitis
varicose veins after surgery
according to
level of
understanding

4. Encourage >To promote >Health teaching

nutrition of tissue healing on the
high protein importance of
and high proper nutrition
caloric intake post-surgery
according to
level of
understanding
Y