Ineffective Tissue Perfusion r/t decrease hemoglobin count
T= 36.0 ‘C
RR = 20cpm
CR = 80bpm
BP = 100 / 70
-pale palpebral conjuctivas
-CRT of 4sec (feet)
-CRT of 3 sec (hands)
-pale palm and sole
-Hgb: 94 g/L
10^12/L (4.0 – 5.0 10^12/L)
(0.55 – 0.65%)
Ineffective tissue perfusion related to decrease hemoglobin count.
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.
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:
- Maintain vital signs within normal range;
- Capillary refill of 2-3 seconds; and
- Absence of pallor
.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.
After my 2 days span of care, my client have improved tissue perfusion as evidenced by:
- Maintained vital signs within normal range:
T = 36. 7
RR = 20 cpm
CR = 80 bpm
BP = 100/70 mmHg
- Capillary refill of 3 seconds;and
- Presence of pallor noted