Ineffective Tissue Perfusion r/t decrease hemoglobin count Reviewed by Momizat on . Cues Objectives: VS: T=  36.0 ‘C RR = 20cpm CR = 80bpm BP = 100 / 70   PA: -pale palpebral conjuctivas -CRT of 4sec (feet) -CRT of 3 sec (hands) -pale muco Cues Objectives: VS: T=  36.0 ‘C RR = 20cpm CR = 80bpm BP = 100 / 70   PA: -pale palpebral conjuctivas -CRT of 4sec (feet) -CRT of 3 sec (hands) -pale muco Rating:
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Ineffective Tissue Perfusion r/t decrease hemoglobin count

Cues

Objectives:

VS:

T=  36.0 ‘C

RR = 20cpm

CR = 80bpm

BP = 100 / 70

 

PA:

-pale palpebral conjuctivas

-CRT of 4sec (feet)

-CRT of 3 sec (hands)

-pale mucosa

-pale palm and sole

Laboratory results:

-Hgb: 94 g/L

(120-160 g/L)

-RBC: 2.9

10^12/L (4.0 – 5.0 10^12/L)

-Hct: 0.28

(0.55 – 0.65%)

Need

Activity Exercise

Nursing Diagnosis

Ineffective tissue perfusion related to decrease hemoglobin count.

Rationale:

Hemoglobin is composed of 2 iron and 2 oxygen. Hemoglobin carries oxygen to the different organs of the body. A decrease level of hemoglobin can alter the perfusion process in the body.

Bibliography:

Black,J. Hawks, J(2009). Medical- Surgical Nursing. Elsevier Saunders 11830 Westline Industrial Drive St. Louis, Missouri 62146.

Objectives of Care

Within my 2 days span of care, my client will be able to improve tissue perfusion as evidenced by:

  1. Maintain vital signs within normal range;
  2.  Capillary refill of 2-3 seconds; and
  3. Absence of pallor

Intervention

.Monitor Vital signs

® Vital signs serve as an indicator if good tissue perfusion is achieved.

 

2. Provide quiet, restful atmosphere

® Conserves energy/lowers tissue O2 demands.

 

3.Remove any constricting clothing from his chest

® Constricting clothing interferes with chest expansion.

 

4. Limit procedures to those that are necessary to provide adequate rest periods.

® Activity increases metabolic and myocardial oxygen demands, further impairing cardiopulmonary tissue perfusion.

 

5. Administer oxygen as ordered

® Oxygen enhances tissue perfusion

 

6. Administer intravenous (IV) fluids as indicated.
Rationale: Replacement of fluids maintains circulating volume and tissue perfusion.

 

7. Maintenance of fluid therapy.

® to keep the hematocrit and blood viscosity within acceptable limits

 

8. Perform preventive such as: Good hand washing and protection from individuals,

® Any compromise in pulmonary function will increase the patient’s hypoxemia.

Evaluation

After my 2 days span of care, my client have improved tissue perfusion as evidenced by:

 

  1. Maintained vital signs within normal range:

T = 36. 7

RR = 20 cpm

CR = 80 bpm

BP = 100/70   mmHg

  1. Capillary refill of 3 seconds;and
  2. Presence of pallor noted
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