Ineffective Tissue Perfusion of Hemophilia

Nursing Diagnosis: Ineffective Tissue Perfusion related to active bleeding
characterized by decreased consciousness, bleeding.

Objectives / Expected outcomes: There was no impairment of consciousness, good capillary refill, bleeding can be resolved

Nursing Interventions

1. Assess the cause of bleeding
2. Assess skin color, hematoma, cyanosis
3. Collaboration in the provision of adequate IVFD
4. Collaboration in the provision of blood transfusion.

Rational:

1. By knowing the cause of bleeding it will assist in determining appropriate interventions for patients
2. Provide information about the degree / adequacy of tissue perfusion and assist in determining appropriate intervention
3. Maintain fluid and electrolyte balance and maximize contractility / cardiac output so that the circulation becomes inadequate
4. Repair / menormalakan red blood cell count and enhance oxygen-carrying capacity to be adequate tissue perfusion.

Source : http://careplannursing.blogspot.com/2012/03/3-nursing-diagnosis-interventions-for.html

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.