P: Anemia

S:”Talaga nga adda ti anemiak”

O:>coherent and conversant
>with ongoing IVF of PNSS 1L x KVO and a sidedrip of PRBC x 4-6 hours with a serial
number 21066-0122 infusing well at left arm.
>with initial VS of: T-36 degrees Celsius, PR-65 bpn, RR-20cpm, BP-110/70 mmhg
>pale conjunctiva
>cold and clammy skin
>decreased capillary refill

Goals: The client will maintain or achieve optimal tissue perfusion to vital organs.

LTO: After three days of nursing interventions, the client will show the following
manifestations:
a. good capillary refill
b. pinkish oral mucosa
c. pinkish conjunctiva
d. increased tolerance to activity
STO: After eight hours of nursing interventions, the client will manifest the following:
a. understanding of the importance of iron
b. undergo blood transfusion without adverse reactions
c. perform deep breathing exercises
A: Ineffective tissue perfusion related to low hemoglobin count
Nursing Interventions Rationale Criteria for evaluation

Dx: : LTO is met if patient

>Monitored vital signs >To obtain data for
every 15 minutes for 1 comparison and vital signs
hour and every 1 hour may change due to adverse
for the following hours. reactions caused by blood
transfusion.
manifests 4 out of 4
manifestations
LTO is partially met if
patient manifests 2 to 3 out
of 4
LTO is not met if patient
manifests none.

>Assess capillary refill >Prolonged capillary refill STO is met if patient

time, skin color, and time, and cold clammy skin
temperature. is indicative of decreased
cardiac output.
> To evaluate underlybing
>Reviewed laboratory causes and early detection
results. of cause facilitates prompt,
effective treatment.
manifests 3 out of 3
manifestations
STO is partially met if
patient manifests 2 out of 3
manifestations.
STO is not met if patient
manifests 0 to 1 out of 3
manifestations

>Monitored for possible >Transfusion reactions

blood transfusion range from mild to life-
reactions. threatening. Telltale signs
and symptoms include fever
and chills, hives and
itching, dyspnea, and
hypotension.

>Checked serial number >To ensure that the right

of PRBC and whole blood product is to be
blood to be transfused. infused and to ensure
client’s safety.

Tx:

>Assisted in hooking >Transfusions are used to

PRBC and whole blood keep the patients number of
for blood transfusion. blood cells at a safe level
since patients hemoglobin
level is 78g/L.

>Assisted patient with

frequent deep breathing
exercises. >Deep breathing exercises
aids in relaxing patients
>Conversed body when she is in stress.
therapeutically.
>To promote trust between
the nurse and the client
since the client is also
>Regulated IV lines and preparing for a operation for
blood transfusion. the following day.
>Blood transfusion is only
for 4-6 hours and