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.

Tag :
Anemia,
Ineffective Tissue Perfusion,
Ineffective Tissue Perfusion related to Anemia