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
- Edema
- Changes in skin characteristics
- Changes in skin temperature
- Bluish
- Impaired sensation
- Cold extremities
- Wound healing is a long
- Voice intestinal hipoaktif
- Nausea
- Abdominal distention
- Abdominal pain
- Changes in blood pressure
- Hematuria
- Oliguria
- Increased BUN and creatinine
- Abnormal speech
- Weakness of the extremities
- Changes in mental status
- Changes in pupil reaction
- Difficulty swallowing
- Changes in motor response
- 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
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
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
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
