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.

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