Tissue

DATE: July 17, 2009 TIME: 11:16am ASSESSMENT: Received pt lying on bed, conscious and coherent, with ongoing IVF of D5LR at 610cc level in 40gtts/min regulation intact and infusing well on the left arm. CUES Subjective: @ Objective: > dry mucous membrane > poor skin turgor > (+) bruising > slow venous filling > (+) melena > CR: 4sec > BP: 90/60 Laboratory Results: Platelet: decreased

NX DIAGNOSIS Ineffective tissue perfusion r/t bleeding tendencies associated with low platelet count 2 to GI bleeding

SCI-EXP Increase vascular permeability within the cell ↓ Plasma leakage ↓ Platelet burst out ↓ Inability to maintain the stability of platelet plug of smaller vessels and capillaries beneath each surfaces ↓ Tissue becomes easily disrupted and tear ↓ Exposure of visceral underlying tissues of the UGIT 2 to enzymatic secretion ↓ UGI bleeding tendencies ↓ Poor tissue perfusion and melena

PLANNING After 1-2hrs of nursing intervention the pt will be able demonstrate an increase in tissue perfusion

INTERVENTION > Monitored vs > Monitored for signs of shock such as weak thready pulse, decrease BP, increase RR, and low urine out put. > Kept pt rested with body erected avoiding flexion > Provided ice packs on the abdomen > Kept pt DAT diet except dark colored food > Changed position q2hrs > Monitored platelet count > Monitored I&O

> Encouraged pt to increase fluid intake at least 1-2L/day if tolerated

RATIONALE > For baseline data > Indicative sign of hypovolemia during severe bleeding > To maintain venous flow stable flexion causes impairment of blood flow to the underlying tissues > To promote vasoconstriction thereby decreasing bleeding tendencies > To monitor for occult blood as an indicative sign of bleeding > To promote venous circulation > Serve as a baseline data and progress note for platelet conditions > Decrease kidney tissue perfusion impairs kidney function resulting to deficit output > To compensate fluid and electrolytes lost

EVALUATION After 1-2hrs of nursing intervention the pt was been able to demonstrate an increase in tissue perfussion as evidenced by > good skin turgor and venous filling > CR: 3 sec >BP: 100/70