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Saturday, February 25, 2012

Anemia - Ineffective Tissue Perfusion Nursing Diagnosis and Interventions

Anemia - Ineffective Tissue Perfusion Nursing Diagnosis and Interventions


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

Independent

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.

Collaboration

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.