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INEFFECTIVE TISSUE PERFUSION RELATED TO ANEMIA. SIGNS AND SYMPTOMS OF ANEMIA. NURSING INTERVENTIONS AND NURSING RATIONALE. PHYSICAL ASSESSMENT AND LABORATORY REPORTS.
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Assessment Nursing Diagnosis
Rationale Goals and Objectives
Nursing Interventions Rationale Evaluation
Objective:-Vital Signs:BP: 80/50RR: 34CR: 120- Low HGB level: 98g/L (normal 120-170g/L)- Low HCT level: 30: anemia (normal 0.37-0.54)-Pale palpebral conjunctiva-Nausea-Edema-Hematuria-Increased BUN and creatinine-Melena-Hematemesis
Ineffective Tissue Perfusion related to anemia
Transport of oxygen is impaired with anemia. In anemia, the Hemoglobin is lacking or number of RBCs is too low to carry adequate oxygen to tissues and hypoxia develops.
After 4.5 hours of nursing interventions, the patient will be able to:
1. Monitor and Record Vital Signs.
2. Maintain on bed rest
3. Assess patient general condition.
4. Encourage quiet and restful atmosphere.
5. Provide safety by raising side rails
6. Administer supplemental oxygen as ordered
7. Administer IV fluids as ordered.
8. Monitor laboratory studies such as hemoglobin, hematocrit and RBC.
9. Blood component therapy (Blood transfusion) as ordered.
10. Render health teachings such as: a. Avoid straining.b. Deep breathing exercisesc. Eat foods rich in iron
1. To have a baseline data.
2. Restricted activity reduces oxygen demands of the heart and other organs.
3. To have a baseline data and note any abnormal findings.
4. To conserve energy and lower tissue oxygen demands.
5. Weakness, fatigue and restlessness are signs of hypoxia which may cause injury to the patient.
6. Oxygen increase arterial saturation.
7. Maintains circulating volume to maximize tissue perfusion.
8. Normal values indicate adequate tissue perfusion.
9. Blood transfusion increases the patient’s blood volume and
After 4.5 hours of nursing interventions, the patient will be able to:
raising the hemoglobin level. Hemoglobin is a component of the red blood cell that carries oxygen to different tissues and organs throughout the body.
10. A. Straining for a bowel movement further impairs cardiac output and it demands more oxygen.B. Deep breathing exercises help in lung expansion.C. to increase the capacity of the RBC to carry oxygen throughout the body.
