POTENTIAL NCP

Needs/Nursing diagnosis Safety and Security needs Risk for innefective protection related to suppressed erythropoietin and RBC production. Objective: - Body Weakness - Fatigue - Body malaise - Pale skin noted Scientific analysis: Anemia develops as a result of inadequate erythropoietin production, the shortened life span of RBC, nutritional deficiencies ad the patients tendency to bleed. Particulary from the GI tract. Erythropoietin a substance normally produced by the kidneys, stimulates bone marrow to produce RBC. In ESRD, erythropoietin production decrease and profound anemia results, producing fatigue, angina and SOB. Source: brunner and suddarths medical surgical nursing Vol. 1 12 th edition, oo:1325

Own analysis: erythropoietin stimulates the bone marrow to produce more red cells and thereby increase the oxygen-carrying capacity of the blood. Since the patients kidneys are damaged, erythropoietin production by the kidneys are decreased and therefore its function to stimulate bone marrow to produce RBC is also decreased. And because RBC is decreased it can lead to anemia . Objectives: After 8 hours of nursing intervention patient will be able to: a. verbalize no signs/symptoms of bleeding/hemorrhage. b. Maintain/demonstrate improvement in laboratory value. Nursing Intervention:

a. Note reports of increasing fatigue, weakness, observe for tachycardia, pallor of skin/mucous membrane, dyspnea and chest pain Rationale: May reflect effects of anemia and cardiac response necessary to keep cell oxygenated. b. Monitor level of consciousness and behavior. Rationale: Anemia may cause cerebral hypoxia manifested by changes in orientation and behavioural response c. Evaluate response to activity to perform task. Assist as needed and develop schedule for resting. a. Rationale: Anemia decrease tissue oxygenation and increases fatigue which may require intervention, and changes in activity d. Observe for oozing from venipuncture sites, bleeding/ecchymotic areas following slight trauma, petechiae; joint swelling or mucous membrane involvement, e.g., bleeding gums, recurrent epistaxis,hematemesis, melena, and hazy/red urine. Rationale: Bleeding can occur easily because of capillary fragility/altered clotting functions and may worsen anemia Collaborative: a. Monitor RBC count, hemoglobin and hematocrit levels as indicated Rationale: Provides assessment of degree of anemia