CUES NSG DIAGNOSIS RATIONALE SPECIFIC OUTCOME NSG.

INTERVENTIONS RATIONALE EVALUATION

INDEPENDENT GOALS PARTIALLY
Subjective: Ineffective tissue Hemoglobin is a complex protein- After 2 days of nursing MET.
perfusion related to iron compound in the blood that intervention the client 1.Assessed and monitored 1. General indicators
“ Danay ako decreased hemoglobin carries oxygen to the cells from the will be able to: vital signs, skin color, of circulatory status After 2 days of nursing
nalilinop ngan concentration in lungs and carbon dioxide away sensation, movement, and and adequacy of intervention, the client
nanluluya tak 1. Demonstrate capillary refill on perfusion. Edema was able to demonstrate
blood. from the cells to the lungs. Each
lawas.” as verbalized increased perfusion extremities. formation can readily slight increased
erythrocyte contains 200 to 300
by the patient. as individually compress blood perfusion as evidenced
molecules of hemoglobin, each appropriate (e.g. vesssels thereby by increased in
molecule of hemoglobin contains hematocrit, impeding circulation hemoglobin (79.0g/L),
four groups of heme, and each hemoglobin, RBC, and increasing venous hematocrit (.22),
Objective: group of heme can carry one WBC, capillary refill, stasis/edema. RBC(2.28 10^12/L)
molecule of oxygen. In an BP within normal and WBC (2.90
- Pallor atmosphere of high oxygen range, absence of 2. assess lower extremities 2. Reduced peripheral 10^9/L) but still with
- Pale palpebral concentration such as in the lungs, edema). for skin texture, edema, circulation often leads the presence of pallor,
conjuctiva hemoglobin binds with oxygen to ulcerations. to dermal changes and edema, delayed
- Pale lips form oxyhemoglobin. In an 2. Maintain adequate delayed healing. capillary refill.
- Thick atmosphere of low oxygen
tissue perfusion as
fingernails evidence by good
concentration, such as peripheral
- Skin capillary refill and
tissues of the body, oxygen is
discoloration normal skin color. 3. Investigated reports of 3. Indicators of
of lower replaced by carbon dioxide to form deep/throbbing ache, decreased
extremities due carboxyhemoglobin. Hemoglobin numbness. perfusion.
to bipedal releases the carboxyhemoglobin in
edema the lungs for excretion and picks
- Capillary refill: up more oxygen for transports to 4. Elevated affected 4. Promotes systemic
4 seconds the cells. extremities, as appropriate. circulation/venous
- Low hgb level- Transport of oxygen is impaired Remove jewelry/armband. return and may reduce
47 g/L with anemia. Hemoglobin is edema or other
( normal hgb deleterious effects of
 count 135-170 lacking or the number of RBCs is constriction of
g/L) too low to carry adequate oxygen edematous tissues.
- RBC of to tissues and hypoxia develops. DEPENDENT
1.33x1012/L The body attempts to compensate
(Normal: Male 4.6- 1. Administer IV 1. Maintains
for tissue hypoxia by increasing the
6.2) fluids/blood products as circulating volume to
rate of RBC production, increase
- Hematocr indicated. (PNSS x KVO maximize tissue
it of 0.14 cardiac output by increase stroke rate) perfusion.
(Normal: volume or heart rate, redistributing
0.40- blood from tissues of low oxygen COLLABORATIVE
0.54) needs, and shifting the oxygen- 1. Normal values
- Leukocyt hemoglobin dissociation curve to 1. Monitor laboratory indicate adequate
es of 2.70 the right to facilitate the removal of studies such as hemoglobin, tissue perfusion.
10^9/L more oxygen by tissues at the same hematocrit and RBC.
(normal: partial pressure of oxygen.
4.5-10.0
10^9/L)
- BP: Reference:
100/70m
mhg Mosby’s Dictionary 4th Edition
(normal: p.629
120/80
mmhg) Medical Surgical Nursing 8th
Edition by Joyce M. Black and
Jane Hokanson Hawks p.