Nursing Diagnosis for Anemia: Ineffective Tissue Perfusion related to the decrease in the cellular components required for the delivery of oxygen / nutrients to the cells.
Objectives: increased tissue perfusion.
Expected outcomes are: - indicates inadequate perfusion, such as stable vital signs.
Ineffective Tissue Perfusion Nursing Interventions for Anemia
1. Monitor vital signs assess capillary refill, color of skin / mucous membranes, nail beds.
Rational: provides information about the degree / adequacy of tissue perfusion and help determine the need for intervention.
2. Elevate head of bed as tolerated.
Rational: increase lung expansion and maximize oxygenation for cellular needs. Note: if there is hypotension contraindicated.
3. Monitor respiratory effort; auscultation of breath sounds adventisius note sounds.
Rational: dyspnea, gurgling menununjukkan heart problems due to strain the old heart / cardiac output increased compensation.
4. Investigate complaints of chest pain / palpitations.
Rational: influence cellular network myocardial ischemia / infarction risk potential.
5. Avoid using a bottle warmer or hot water bottle. Measure the temperature of bath water with a thermometer.
Rational: termoreseptor superficial dermal tissue due to disruption of oxygen.
1. Keep an eye on the results of laboratory examination. Give a complete red blood cell / blood product packed as indicated.
Rational: identify deficiencies and needs treatment / response to therapy.
2. Provide supplemental oxygen as indicated.
Rational: to maximize the transport of oxygen to the tissues.