Nursing Diagnosis for Anemia : Ineffective Tissue perfusion
Anemia is a symptom of an underlying condition, such as loss of blood components, elements inadequate or lack of nutrients needed for the formation of red blood cells, resulting in decreased oxygen-carrying capacity of blood (Doenges, 1999).
Anemia happens when:
Symptoms:
Nursing Diagnosis for Anemia : Ineffective Tissue perfusion related to decreased cellular components required for the delivery of oxygen / nutrients to the cells.
Goal: increase tissue perfusion.
Outcomes: indicates adequate perfusion, such as vital signs stable.
Interventions and Rational:
Independent
1. Monitor vital signs, assess capillary refill, skin color / mucous membranes, nails.
Rational: provides information about the degree / adequacy of tissue perfusion and help determine the need for intervention.
2. Elevate the head of bed as tolerated.
Rational: increased lung expansion and maximize oxygenation to cellular needs. Note: contraindicated if there is hypotension.
3. Monitor respiratory effort: auscultation of breath sounds adventisius notice.
Rational: dyspnea, heart problems because of the rush shows old heart strain / compensatory increase in cardiac output.
4. Investigate complaints of chest pain / palpitations.
Rational: cellular ischemia affects myocardial tissue / potential risk of infarction.
5. Avoid using the bottle warmers or hot water bottle. Measure the temperature of bath water with a thermometer.
Rational: thermoreceptor superficial dermal tissue for oxygen interference.
Collaboration
1. Monitor results of laboratory examination. Give a complete red blood cells / 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 tissues.
Anemia is a symptom of an underlying condition, such as loss of blood components, elements inadequate or lack of nutrients needed for the formation of red blood cells, resulting in decreased oxygen-carrying capacity of blood (Doenges, 1999).
Anemia happens when:
- The body loses too much blood (such as with heavy periods, certain diseases, and trauma); or
- The body has problems making red blood cells; or
- Red blood cells break down or die faster than the body can replace them with new ones; or
- More than one of these problems happen at the same time.
Symptoms:
- Weakness
- Shortness of breath
- Dizziness
- Fast or irregular heartbeat
- Pounding or “whooshing” in your ears
- Headache
- Cold hands or feet
- Pale or yellow skin
- Chest pain
Nursing Diagnosis for Anemia : Ineffective Tissue perfusion related to decreased cellular components required for the delivery of oxygen / nutrients to the cells.
Goal: increase tissue perfusion.
Outcomes: indicates adequate perfusion, such as vital signs stable.
Interventions and Rational:
Independent
1. Monitor vital signs, assess capillary refill, skin color / mucous membranes, nails.
Rational: provides information about the degree / adequacy of tissue perfusion and help determine the need for intervention.
2. Elevate the head of bed as tolerated.
Rational: increased lung expansion and maximize oxygenation to cellular needs. Note: contraindicated if there is hypotension.
3. Monitor respiratory effort: auscultation of breath sounds adventisius notice.
Rational: dyspnea, heart problems because of the rush shows old heart strain / compensatory increase in cardiac output.
4. Investigate complaints of chest pain / palpitations.
Rational: cellular ischemia affects myocardial tissue / potential risk of infarction.
5. Avoid using the bottle warmers or hot water bottle. Measure the temperature of bath water with a thermometer.
Rational: thermoreceptor superficial dermal tissue for oxygen interference.
Collaboration
1. Monitor results of laboratory examination. Give a complete red blood cells / 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 tissues.
