Subjective:> easy fatigability> pt. reports of a decrease in physical activity after her Tenkoff catheter insertion (from regular ambulation to just sitting/standing and minimal ambulation w/ assistance in going to the bathroom)

Objective:> capillary refill time 4 seconds in fingernails and 5 seconds toenails> radial and dorsalis pedis pulses with a grade of +1/+4> extremities appear more pale and cooler than the rest of the body

Assessement:Ineffective tissue perfusion: peripheral r/t mechanical reduction of peripheral blood flow secondary to decreased physical activity.

Planning:After 2 hours of nursing intervention, pt.’s peripheral circulation will improve as evidenced by:a. increase in peripheral pulse gradeb. decrease in capillary refill timec. improvement in the color and temperature of extremitiesd. general increase in activity tolerance

Implementation:>Instructed to perform ADLs independently without assistance whenever possible.>Demonstrated 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 neckb. arms and handsc. legs, knees and feet>Assisted in adopting a plan to integrate independent ADL performance and ROM exercises in her daily routine. > Provided arm, hand, leg and feet massage.> Kept pt.’s feet warm by putting on socks or use a blanket.

Evaluation:After 2 hours, peripheral circulation has improved as evidenced by:a. increase in radial and dorsalis pedis pulse grade (from +1/+4 to +2/+4)b. decrease in capillary refill time in extremities ( from > 3 seconds to < 3 seconds)c. improvement of color and temperature of skin in extremities (from pale-looking and cool to pinkish and warm)d. verbalization of an increase in activity tolerance and independent performance of ADLs

S: >O: nasal flaringuse of accessory muscle to breathshallow breathingabdominal enlargement due to the presence of ascitesabdominal girth is 44 incheswith tenkhoff catheter on peritoneal cavitywith cutdown catheter on ® basilic veinA: Ineffective breathing pattern r/t increased pressure in the diaphragm 2° accumulation of fluid in the peritoneal cavity P: Within 3hrs of proper nursing interventions the client breathing pattern will be improveI: kept the head of bed in elevated positionassisted patient in a comfortable positiondemonstrated to patient how to do deep breathing exercisesinstructed to restrict or decrease fluid intake and maintain low fat and low salt dietassisted patient in draining ascitic fluid.E: After 3hrs of proper nursing intervention clients breathing pattern has been improved as manifested by non-shallow breathing, no use of accessory muscle, and no episodes of nasal flaring during respiration