Ineffective Tissue Perfusion related to Anemia
NCP for (Anemia)
Ineffective Tissue Perfusion – related to a decrease in the cellular components required for the delivery of oxygen / nutrients to the cells.
Characterized by :
Capillary refill time (CRT) is more than 3 seconds, cyanosis, pale skin, dry mucous membranes, nails and hair brittle.
Having given nursing actions during 3×24 hours, is expected to increase tissue perfusion
Criteria results :
- Indicates adequate perfusion, such as stable vital signs.
- Cyanosis does not occur.
- Capillary refill time (CRT) of less than 3 seconds.
- The skin is not pale.
- Mucous membranes moist.
- Nails and hair strong.
Interventions :
- Provide supplemental oxygen as indicated.
- Keep an eye on vital signs assess capillary refill time, color of skin / mucous membranes, nail beds.
- Elevate head of bed as tolerated.
- Assess complaints of chest pain / palpitations.
- Collaborative monitoring laboratory test results. Give a complete red blood cells / blood product packed as indicated.
Rationale :
- Maximizing oxygen transport to the tissues.
- Provide information about the degree / tissue perfusion adequacy and help determine the need for intervention.
- Improving lung expansion and oxygenation to maximize cellular needs.
- Myocardial tissue ischemia affects cellular / potential risk of infarction.
- Identify deficiencies and needs treatment / response to therapy.