CUES Subjective: “ Danay ako nalilinop ngan nanluluya tak lawas.” as verbalized by the patient.
Objective: - Pallor - Pale palpebral conjuctiva - Pale lips - Thick fingernails - Skin discoloration of lower extremities due to bipedal edema - Capillary refill: 4 seconds - Low hgb level47 g/L ( normal hgb count 135-170 g/L) - RBC of 1.33x1012/L (Normal: Male 4.66.2) - Hematocr it of 0.14 (Normal: 0.400.54) - Leukocyt es of 2.70
NSG DIAGNOSIS
RATIONALE
Ineffective tissue perfusion related to decreased hemoglobin concentration in blood.
Hemoglobin is a complex proteiniron compound in the blood that carries oxygen to the cells from the lungs and carbon dioxide away from the cells to the lungs. Each erythrocyte contains 200 to 300 molecules of hemoglobin, each molecule of hemoglobin contains four groups of heme, and each group of heme can carry one molecule of oxygen. In an atmosphere of high oxygen concentration such as in the lungs, hemoglobin binds with oxygen to form oxyhemoglobin. In an atmosphere of low oxygen concentration, such as peripheral tissues of the body, oxygen is replaced by carbon dioxide to form carboxyhemoglobin. Hemoglobin releases the carboxyhemoglobin in the lungs for excretion and picks up more oxygen for transports to the cells. Transport of oxygen is impaired with anemia. Hemoglobin is lacking or the number of RBCs is too low to carry adequate oxygen to tissues and hypoxia develops. The body attempts to compensate for tissue hypoxia by increasing the rate of RBC production, increase cardiac output by increase stroke volume or heart rate, redistributing blood from tissues of low oxygen needs, and shifting the oxygenhemoglobin dissociation curve to the right to facilitate the removal of more oxygen by tissues at the same
SPECIFIC OUTCOME After 2 days of nursing intervention the client will be able to: 1. Demonstrate increased perfusion as individually appropriate (e.g. hematocrit, hemoglobin, RBC, WBC, capillary refill, BP within normal range, absence of edema). 2. Maintain adequate tissue perfusion as evidence by good capillary refill and normal skin color.
NSG. INTERVENTIONS INDEPENDENT 1.Assessed and monitored vital signs, skin color, sensation, movement, and capillary refill on extremities.
2. assess lower extremities for skin texture, edema, ulcerations.
RATIONALE
EVALUATION GOALS PARTIALLY MET.
1. General indicators of circulatory status and adequacy of perfusion. Edema formation can readily compress blood vesssels thereby impeding circulation and increasing venous stasis/edema.
After 2 days of nursing intervention, the client was able to demonstrate slight increased perfusion as evidenced by increased in hemoglobin (79.0g/L), hematocrit (.22), RBC(2.28 10^12/L) and WBC (2.90 2. Reduced peripheral 10^9/L) but still with circulation often leads the presence of pallor, to dermal changes and edema, delayed delayed healing. capillary refill.
3. Investigated reports of deep/throbbing ache, numbness.
3. Indicators decreased perfusion.
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4. Elevated affected extremities, as appropriate. Remove jewelry/armband.
4. Promotes systemic circulation/venous return and may reduce edema or other deleterious effects of constriction of edematous tissues.
DEPENDENT 1. Administer IV fluids/blood products as indicated. (PNSS x KVO rate)
1. Maintains circulating volume to maximize tissue perfusion.
COLLABORATIVE 1. Monitor laboratory studies such as hemoglobin,
1. Normal values indicate adequate tissue perfusion.
