Nursing Care Plan Assessment Ineffective tissue perfusion related to decrease hemoglobin concentration in blood as manifested by; S: Medyo

nahihirapan akong huminga at madali akong mapagod. O: Body weakness Restlessness Easy fatigability Capillary refill time 4 seconds Use of accessory muscle for breathing Alter skin characteristics. Planning Intervention Rationale Performance of ADLs without aid increases the pt.s level of physical activity as well as independence. Performing active ROM increases the pt.s level of physical activity as well as independence. Expected Outcome The patient will be able to understand and give comments about the discussion as evidenced by; a.) Verbalized understanding of the condition and therapy regimen. b.) Demonstrate lifestyle changes to improve circulation.

After 8 hrs of duty, the 1. Instruct the patient to perform ADLs client will be able; independently without assistance whenever a) Verbalize understanding of condition therapy regimen. b) Demonstrate life style changes to improve circulation

possible. 2. Demonstrate to the pt. how to perform active ROM exercises and assist pt. as needed. Increase the intensity and duration of each set of exercises as tolerated. a. head and neck b. arms and hands c. legs, knees and feet 3.) Assist the patient in adopting a plan to integrate independent ADL performance and ROM exercises in her daily routine. Plan for time duration frequency and intensity and give positive reinforcements as patient progresses. 4.) Provide arm, hand, leg and feet massage

Formulation of a daily plan of activities by the patient herself helps make compliance easier and more regular.

Massaging of the extremities promotes blood circulation and aid in venous blood return.

Warm temperature causes localized vasodilatation of the 5.) Keep pt.s feet warm by putting on socks blood vessels in the area where it or use a blanket. Apply warm compress if is applied which increases blood desired or tolerated by the pt. for a flow to that area. maximum time or 15 minutes per area. To determine location/severity of Review results of diagnostic studies (x-rays, condition. ultrasound) To treat and alleviate the condition Administer prescribed medication on time