NURSING DIUAGNOSIS

INEFFECTIVE TISSUE PERFUSION RELATED TO DECREASED HEMOGLOBIN CONCENTRATION IN THE BLOOD AS EVIDENCED BY PALLOR OBJECTIVE: Pallor Pale conjunctiva Body weakness Hemoglobin: 124 (normal: 140- 180)

ANALYSIS

GOAL AND OBJECTIVE

NURSING INTERVENTION

RATIONALE

EVALUATION

Decrease GOAL INDEPENDENT: intravascular volume After 8 hours of -monitor vital signs Nursing intervention, patient will be able Decrease in cardiac to have an effective output tissue perfusion -measure urine output on a regular OBJECTIVE basis antidiuretic hormone aldosterone secretion -after 4 hours of nursing intervention the patient will be able to have increase capillary refill -after 2 hour of nursing intervention the patient will not experience DOB -encourage ambulation

-to have a baseline data

Was the patient able to have an effective tissue perfusion? YES__ NO__WHY__

-to monitor patients hydration

-promotes venous circulation

Was the patient able to have increase capillary refill? YES__NO__WHY__ Was the patient dont experience DOB? YES__ NO__ WHY__

-promote adequate fluid intake

- prevents stasis of the body fluids

increase volume, increase heart rate force of contractions

-advised to eat iron rich foods -provide a quiet environment

-for blood production -for patient to have rest periods

increase cardiac output

continue loss of volume

DEPENDENT -administer medications as needed -drugs use to improve tissue perfusion

decrease cardiac output COLLABORATIVE -review specific -specific nutrients are needed to meet

decrease tissue perfussion

dietary changes with client

the needs of the patient

HEALTH TEACHING PLAN

Learning Objective Learning Content Rationale Method Resourc es Evaluation

GOAL After 8 hours of Nursing interventi on, patient will be able to have an effective tissue perfusion OBJECTI VE -after 4 hours of nursing interventi on the patient will be able to have

IPAALAM ANG ANG MGA PARAAN UPANG MAKAMIT ANG MAGANDANG NUTRISYON: Uminom ng maraming tubig Kumain ng mga gulay Ugaliing mag eherisiyo kahit maglakad Wag magpapagod at panatilihiin ang pagkakaroon ng sapat na pahinga

Recitation Discussion Money Visual aids Doing this interventions will promote tissue perfusion

Time and effort of the students

increase capillary refill -after 2 hour of nursing interventi on the patient will not experienc e DOB