Ineffective Tissue Perfusion related to Anemia

Saturday, April 14, 2012 ·


Nursing Diagnosis for Anemia: Impaired Tissue Perfusion

Definition: Decrease in oxygen resulting in damage to tissue maintenance.

Defining characteristics:
1. Cardiopulmonary
  • Changes in respiratory frequency
  • The use of additional respiratory muscles
  • Abnormal blood gas analysis
  • Dyspnea
  • Arrhythmias
  • Chest pain
  • Chest retraction
  • Capilary refill more than 3 seconds
  • Bronchospasm
2. Peripheral
  • Edema
  • Changes in skin characteristics
  • Changes in skin temperature
  • Bluish
  • Impaired sensation
  • Cold extremities
  • Wound healing is a long
3. Gastrointestinal
  • Voice intestinal hipoaktif
  • Nausea
  • Abdominal distention
  • Abdominal pain
4. Renal
  • Changes in blood pressure
  • Hematuria
  • Oliguria
  • Increased BUN and creatinine
5. Cerebral
  • Abnormal speech
  • Weakness of the extremities
  • Changes in mental status
  • Changes in pupil reaction
  • Difficulty swallowing
  • Changes in motor response
Related factors:
  • Decrease in hemoglobin in the blood

Diagnosis, Goals, Outcomes, Nursing Interventions:

Ineffective tissue perfusion related to decrease in hemoglobin in the blood

NOC 1:
Status of peripheral and cerebral tissue perfusion
Criteria:
  • Filling capilary refil
  • The power of peripheral pulse distal
  • The power of the proximal peripheral pulsation
  • Symmetry proximal peripheral pulsation
  • The level of normal sensation
  • The color of normal skin
  • The power of muscle function
  • Integrity of the skin
  • Warm skin temperature
  • There was no peripheral edema
  • There is no pain in the extremities
NOC 2:
Circulation status
Criteria:
  • Blood pressure was within normal limits
  • The power of the pulse within normal limits
  • The average blood pressure within normal limits
  • Central venous pressure within normal limits
  • There was no orthostatic hypotension
  • There is no additional heart sounds
  • There is no angina
  • There was no orthostatic hypotension
  • Analysis of blood within normal limits as
  • Difference in arterial and venous oxygen levels are normal
  • No additional breath sounds
  • The power of peripheral pulse
  • No widening of the veins
  • There was no peripheral edema

NIC:

1. Circulation treatment
activities:
  • Check the peripheral pulses
  • Record the color and temperature
  • Check the refill capilery
  • Record prosntase edema, especially in the extremities
  • Do not exceed the elevation of the hands of the heart
  • Keep the client warm
  • Monitor fluid status, input and output sesuaiMonitor lab Hb and HMT
  • Monitor bleeding
  • Monitor hemodynamic status, neurological and vital signs
2. Monitor vital signs
activities:
  • Monitor blood pressure, pulse, temperature and respiration
  • Note the fluctuations in blood pressure
  • Monitor blood pressure at the time the client lying down, sitting and standing
  • Measure blood pressure in both arms and compare
  • Monitor blood pressure, pulse, respiration, before, during and after activity
  • Monitor heart rate and rhythm
  • Monitor heart sound
  • Monitor respiratory rate and rhythm
  • Monitor lung sounds
  • Monitor abnormal rhythm of the breath
  • Monitor temperature, color and moisture
  • Monitor peripheral cyanosis
3. Monitor neurological status
activities:
  • Monitor the size, shape, kesmetrisan and pupillary reaction
  • Monitor level of consciousness
  • Monitor the level of orientation
  • Monitor GCS
  • Monitor vital signs
  • Monitor patient response to treatment

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