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Nursing Diagnosis: Ineffective tissue perfusion.

(arterial, venous, and peripheral) related to impaired transport of oxygen across alveolar and or capillary membrane, exchange problems; interruption of venous flow; mechanical reduction of venous and arterial blood flow, decreased hemoglobin in the blood. Supportive data: 1. Patient presented to hospital with low blood pressure (BP 99/51). 2. Patient presented to hospital with low Hgb and Hct levels. (Hgb 7.7 g/dl & Hct 22.9%, RBC count 1.95 mill/mm3) 3. Patient has cool and pale skin. 4. Patient is weak, experiences exertional dyspnea with minimal mobility. 5. Patient presented to hospital after 3 months frank red blood in colostomy bag and a history of colorectal cancer and chemotherapy treatments. 6. Patient received infusion of blood therapy, 2 units, due to low Hgb (7.7g/dl) and Hct (22.9%)

Age: 73 Room #: 714 Medical Diagnosis: Anemia, and weakness

Goal 1. While in the hospital the patient will demonstrate adequate tissue perfusion as evidenced by palpable peripheral pulses, warm and dry skin, and absence of respiratory distress, and maintaining a capillary refill time of 3sec, and maintaining a 95% on pulse oximetry. AEB: Pulses were palpable in all extremities, the patient did not appear to be in respiratory distress and skin was warm and dry to the touch, the patient maintained an SaO2 >95% and capillary refill <3sec. 2. While in the hospital patients Hgb and Hct and levels will rise and be within normal limits,(a decrease in RBC may have an adverse effect on oxygen transport) while showing no signs and symptoms of adverse reactions to blood products. AEB: Patient received 2units of blood and vital signs were assessed when blood transfusion was completed.

Interventions 1. Assess oxygenation, obtaining and maintaining an SaO2 >95%. 2. Monitor peripheral pulses. If there is a new onset of loss of pulses with bluish, purple or black areas and extreme pain, notify the physician immediately. 3. Assess and note patients skin color and feel the temperature of the skin. 4. Assess patient for pain in the extremities, noting severity, quality, timing and exacerbating and alleviating factors. Differentiate venous from arterial disease. 5. Patient will receive blood product therapy to increase tissue perfusion. 6. Asses patients Hgb and Hct and RBC after the completion of blood transfusion and note positive and/or negative changes. 7. Assess and monitor vital signs when blood transfusion is completed, and monitor for any signs of adverse reaction to blood products.

Evaluations 1. Goal Met: Pedal pulses checked and present but pulses were decreased and weak, patient was wearing socks, which were applied with AM care. Patients skin was warm and dry to the touch and intact, with no visible signs of cyanosis and a capillary refill of < 3seconds, patient denied pain, tenderness, but there was visible signs of edema (2+) noted on lower extremities. 2. Goal Met: The patients neck veins did not appear visibly engorged, no rales or rattling heard upon auscultating the chest, and there was no sign of a rapid rise in the patients blood pressure or other changes in his VS. Start 108/51 87 18 98.2 97% End 119/70 91 18 97.9 97%

BP Pulse Resp. Temp. O2 3.

Goal Not Met: Unable to assess because lab work to assess CBC was ordered for Friday morning.

Vital Signs after blood transfusion completed: B/P: 119/70 Temp: 97.9 F SaO2: 97% Resp: 18 Pulse: 91 Before blood transfusion Hct 22.9% Hgb 7.7g/dl RBC 1.95 mill/mm3

Nursing Diagnosis List Age: 73 Room #: 714 Date: 9/8/2011 Medical Diagnosis: Anemia and Weakness

Summary of Patient history and description of Medical Diagnosis: Patient is a 73 year old Caucasian who presented to the hospital with bleeding per colostomy for about 3 months, complaining of weakness, and shortness of breath, hypotension, he has a history of colorectal cancer and chemotherapy treatment, it was noted in his file that he is an ongoing ETOH user (6 vodka drinks per day). Priority Day 1 1 Priority Day 2 1 Nursing Diagnosis Risk for ineffective tissue perfusion. (arterial, venous, and peripheral) related to impaired transport of oxygen across alveolar and or capillary membrane, exchange problems; interruption of venous flow; mechanical reduction of venous and arterial blood flow, decreased hemoglobin in the blood. Patient presented to hospital with low blood pressure (BP 99/51). Patient presented to hospital with low Hgb and Hct levels. (Hgb 7.7 g/dl & Hct 22.9%, RBC count 1.95 mill/mm3) Patient has cool and pale skin. Patient is weak, experiences exertional dyspnea with minimal mobility. Patient presented to hospital after 3 months frank red blood in colostomy bag. Patient has a history of colorectal cancer and chemotherapy treatments. Risk for Infection: increased risk for being invaded by pathogenic organisms related to inadequate secondary defenses. AEB: Patients inadequate secondary defenses Patients history of colorectal cancer. Patient has a colostomy as a result of a history of colorectal cancer. Patients has a WBC level of 6.2

Impaired Gas exchange excess or deficit related to oxygen supply AEB: Patient experiencing dyspnea when ambulating to bathroom. (This is abnormal for pt., he states that he was able to better tolerate this type activity in previous years.) Patient experiencing tachycardia related to low blood pressure as a result of blood loss. blood pressure---- 99/51 normal value BP--- 120/80 (the range varies with each individual) decreased hemoglobinpt. value 7.7 g/dl (normal values------14-16 g/dl) decreased hematocrit----pt. value 22.9% (normal values-----41-53%) decreased RBC count--- 1.95 mill/mm3 (normal values--- 4.3 - 5.9 mill/mm3) Deficient Fluid Volume r/t active fluid loss due to bleeding AEB: Patient brought to hospital due to 3 months of bleeding per colostomy. Patient experiencing hypotension due to hypovolemia. (BP 99/51) Patient will have blood products administered. Patients skin turgor is poor; the skin appears to have poor elasticity. . Risk for circulatory overload related to blood product administration AEB: Patient has weak pulses in all extremities, they are cool to the touch, and there is edema present in both lower extremities Patient was administered two units of blood. Patient received blood products via pump at a rate of 80ml per hour for the first 15 min, then the primary nurse set the infusing pump at 125 ml per hour. Patient did not show any signs and symptoms of fluid overload during the treatment. Risk for Injury related to blood component transfusion therapy (potential for hemolytic reaction, allergic reaction, febrile transfusion reaction). AEB: Patient was administered two units of blood.

Discharge Planning Diet:

Eat a healthy variety of foods: fruits, vegetables, breads, meats and fish, and dairy products. Aim to consume at least on fruit and on vegetable with each meal. (1 cup of fruit or 100% fruit juice, or cup of dried fruit can be considered as 1 cup from the fruit group, 1 cup of raw or cooked vegetables or vegetable juice, or 2 cups of raw leafy greens can be considered as 1 cup from the vegetable group.) Replace most of the red meat in your diet with leaner cuts, such as chicken and turkey (three ounces of cooked chicken, turkey, or other poultry) these contain protein and iron to help rebuild the iron stores you may have lost during bleeding episodes (1 ounce of meat, poultry or fish, cup cooked dry beans, 1 egg, 1 tablespoon of peanut butter, is for the maintenance of tissue (such as skin, blood cells, muscles, etc.) in adulthood.) Eating foods high in vitamin C is the same as foods high in iron increases iron absorption.

Eat three small meals plus three snacks per day. Eat regularly to avoid periods of hunger. Take Folic acid (folate) to help the body form red blood cells. Take Vitamin A to keep your eyes and skin healthy, it also helps to protect against infections. Take Vitamin E which is an essential fatty acid for cell oxidation. Take Vitamin C helps heal cuts and wounds and keeps teeth and gums healthy. Vitamin C also aids in iron absorption. Drink six to eight (8 ounce) cups of liquid each day (follow your caregiver's advice if you must limit the amount of liquid you drink). Decrease the amount of caffeine you eat and drink. Caffeine may be found in coffee, tea, soda, sports drinks, chocolate, and food bars. Alcohol acts as an intestinal irritant. Excessive drinking also causes varices, dilated blood vessels in the esophagus and other parts of the GI tract that can rupture, causing sometimes massive hemorrhage. Your doctor may suggest that you drink no alcohol at all, especially if you drink excessively.

Activity: Patient is able to ambulate, reinforce the importance of walking at least once peer day with supervision. Avoid overexertion. Medication: The patient will be instructed on any of the medication he will be sent home with, their side effects and what he needs to do if there is any changes while on the medication regimen. Keep a written list of the medicines you take, the dose, when and why you take them. There are many medicines that may cause GI bleeding, do not take any medicines, over-the-counter drugs, vitamins, herbs, or food supplements without first talking to caregivers. Do not take any medicine that has aspirin, naproxen, or ibuprofen in it without first asking your caregivers. Always take your medicine as directed by caregivers. Call your caregiver if you think your medicines are not helping, or if you feel you are having side effects. Do not quit taking your medicines until you discuss it with your caregiver. If you are taking antibiotics, take them until they are all gone even if you feel better.

Take medicines as directed. Patient medication list: Maalox take 20-60 mins after meals Thiamine (Vitamin B1) 100ml/Oral/2-3 x day Tagamet 300 mg/4xday diphenhydramine (Benadryl) 50 mg/day

Folic acid 1 mg/Oral/1 x day Theregran (Multivitamin) 1tab/day

Follow up: This patient is currently under the care of a primary health care provider. Friend should be instructed to maintain any scheduled home visits from nurse. Ensure that friend maintains all appointments and has the means to transport the patient if needed. Instruct patient to call Dr. NON-INVASIVE CARDIOLOGY AND INTERNAL MEDICINE H. Kent Beasley, M.D. at the Capital Medical Clinic to report any signs of infection, distress or with any questions. In the event of an emergency, call 911. Capital Medical Clinic 1301 W. 38th Street, Suite 601 Austin, Texas 78705-1069 Telephone: (512) 454-5171 Fax: (512) 454-0704

Wound care: Write down questions you have, this will help you to remember to ask these questions during your next visit. This pt has a colostomy on the LLQ. Review proper technique for cleaning and taking care of the stoma with his friend, teach signs and symptoms of possible infection, including redness, warmth at site, swelling of tissues, and drainage from wound. Also teach the patient and their caregiver about the effects of anemia on the immune system and how it will also delay wound healing. Skin should be inspected daily for breakdown or areas of redness that do not blanch as this may be a sign of breakdown and possible decubitus ulcer formation. Where is the patient being discharged and who will assist? Patient will be discharged to home with his friend; she will be providing his transportation. Discharge teachings: Discuss the importance of a healthy diet and the benefits the different food groups has on wound healing. Review medications and administration technique for both PO's and subcutaneous injections. Review signs and symptoms of infection and plan of action if one is suspected. Review proper wound care and dressing changing technique

Diagnostic Study: WBC

Diagnostic Study:


Purpose/definition: The total number of WBCs (leukocytes) in 1 mm3 of peripheral venous blood. The differential, which is the percentage of each type of leukocyte present in the same specimen. The purpose of WBCs is to fight infection and respond immediately to foreign invaders. Normal range: 4.5-10. mm3

Purpose/definition: This test is a count of the number of circulating RBCs in 1mm3 of peripheral venous blood. RBCs act as the transport and exchange system for carrying oxygen to the tissues and carbon dioxide away from the tissues. Normal range: 4.70-5.25 million/mm3

Results: 6.2 mm3 Significance in patient & nursing implication: The most common cause of decreased white blood cell count is due to hematopiuetic diseases. Monitor the Patient for signs of infection because an individual who has a low white blood cell count, his or her body becomes susceptible to serious illnesses and infections.

Results: 1.95 million/mm3 Low Significance in patient & nursing implication: The patient is vitamin deficient due to his history of colorectal cancer, chemotherapy treatment and alcohol use.

Diagnostic study: Hemoglobin (Hgb) 3 Purpose/definition: Hemoglobin is what gives the red color to your blood. It contains the iron, which carries the oxygen to the cells. The hemoglobin level indicates the amount of intracellular iron; hence, its value in determining anemia. Normal range: 14.0 to 15.0 g/dl Results: 7.7 g/dl Low Significance in patient & nursing implications: This patient has blood loss per colostomy and history of colorectal cancer and chemotherapy treatment. The nurse should continue to monitor the patients HGB levels after blood transfusion and also monitor the patients SaO2. The nurse should also encourage the patient to eat foods with iron and protein because these nutrients will assist in making more RBC's.

Diagnostic study: Hematocrit (HCT) 4 Purpose/definition: The most precise methods of determining the degree of anemia or polycythemia (excessive amount of red blood cells). The hematocrit represents the volume of red blood cells in 100ml of blood and is therefore reported as a percentage. Normal range: 42.0 to 48.0% Results: 22.9% Low Significance in patient & nursing implications: This patient has decreased levels due to blood loss and has a history of colorectal cancer and chemotherapy treatment. A low hematocrit and hemoglobin usually indicates decreased production, excessive loss, or destruction of red blood cells. Anemia is not a disease, but a term indicating insufficient hemoglobin to deliver oxygen to the cells. The conditions associated with an increased or decreased hematocrit are the same as for hemoglobin. The nurse should monitor the patient for signs of shock due to blood loss. Diagnostic Study: PT (Prothrombin Time) 6 Purpose/definition: Is a blood test that measures how long it takes blood to clot. A prothrombin time test can be used to check for bleeding problems. PT is also used to check whether medicine to prevent blood clots is working. Find a cause for abnormal bleeding or bruising. The lack of some clotting factors can cause bleeding disorders such as hemophilia, which is passed in families (inherited). Check for a low level of vitamin K. Vitamin K is needed to make prothrombin and other clotting factors. Check how well the liver is working. Normal range: 11-12.5

Diagnostic Study: BUN (BLOOD UREA NITROGEN) 5 Purpose/definition: Test is to test whether the kidneys of the patient undergoing the test are functioning in the right manner or not. It is also possible to detect any kidney diseases which the person might be suffering, by using this test. From the results of this test, it is possible to properly detect the problem of dehydration in patients. Urea is formed by the liver in the process of ridding the body of ammonia which is built up as protein you eat is broken down.

Normal range: 12-20mg/DL

Results: 10 mg/dl Low Significance in patient & nursing implications: The patient is vitamin deficient due to his history of alcohol use from unbalanced diets, history or colorectal cancer and chemotherapy treatments. The prime cause of low Bun levels is believed to be the intake of food which is very low in protein content. Many people who are malnourished have very low Bun levels. Consumption of liquids in excessive quantities and beyond the normal limits, can also lead to low bun levels. Liver damage is also one of the major causes of low bun levels.

Results: 13.5 Significance in patient & nursing implications: The patient has a history of colorectal cancer and chemotherapy treatment, and alcohol use, and presented to the ED with bleeding per colostomy. The nurse should monitor the client for any signs or symptoms of bleeding. A longer-than-normal PT can mean a lack of or low level of one or more blood clotting factors (factors I, II, V, VII, or X). It can also mean a lack of vitamin K; liver disease, such as cirrhosis; or that a liver injury has occurred. A longer-than-normal PT can also mean that you have disseminated intravascular coagulation (DIC), a lifethreatening condition in which your body uses up its clotting factors so quickly that the blood cannot clot and bleeding does not stop.

Diagnostic Study: Random Distribution of Width (RDW) 7 Purpose/definition: The RDW stands for Random Distribution of red cell Width. This value tells how consistent are the size of the red blood cells. Newly made cells (reticulocytes), B12 and folic acid deficient cells are larger than iron deficient cells. This is an electronic index that may help clarify if an anemia has multiple components. The high RDW helps determine if there is only a B12 and/or folic acid deficiency (with normal RDW showing the red cells are mostly the same size) or with concomitant iron deficiency (a high RDW due to small and large red blood cells). Normal range: 13 Results: 16.5 High Significance in patient & nursing implications: The patient has a history of colorectal cancer and chemotherapy treatment, alcohol use and is deficient in multiple vitamins. The nurse should continue monitoring the patient to determine if the deficiency in B12 and folic acid increases.

Diagnostic Study: Occult Blood 8 Purpose/definition: Occult blood in the feces usually indicated gastrointestinal bleeding. Occult blood in the feces may be present days or several weeks after a single bleeding episode. False positive occult blood test results may be due to ingestion of meats, poultry, fish and certain drugs.

Normal range: Negative Results: Positive Significance in patient & nursing implications: The patient presented to the ED with bleeding per colostomy. The nurse should teach patient to monitor his stools for any abnormal colored stools, and be sure to report it immediately.

Medication Drug/generic Name Folic acid (Folate --B vitamin) Dose/route/frequency 1 mg/Oral/1 x day Indication Drug/generic Name Thiamine (Vitamin B1) Dose/route/frequency 100ml/Oral/2-3 x day Indication

Stimulates production of RBCs, WBCs and platelet Patient is on this drug because he is deficient in this vitamin due to his history of colorectal cancer, chemotherapy treatment, alcohol use and unbalanced diet.

Is used to prevent or treat low levels of vitamin B1 in people who do not get enough of the vitamin from their diets. Most people who eat a normal diet do not need extra vitamin B1. However, some conditions (such as alcoholism, cirrhosis, stomach/intestinal problems) can cause low levels of vitamin B1. Vitamin B1 plays an important role in the body. It is needed to maintain the health of the nerves and the heart. Low levels of vitamin B1 may cause heart failure and mental/nerve problems. Patient is on this drug because he is deficient in this vitamin due to his history of colorectal cancer, chemotherapy treatment, alcohol use, and from unbalanced diets. Major side effects Rash, itching/swelling (especially of the face/tongue/throat) Severe dizziness Trouble breathing

Major side effects Rash Hives Difficulty breathing Tightness in the chest Swelling of the mouth, face, lips, or tongue Pain, redness. swelling at the injection site folic acid Implementation Do not confuse folic acid with folinic acid (leucovorin calcium) Because of infrequency of solitary vitamin deficiencies, combinations are commonly administered (see combination drugs) May be given subcut, deep IM, or IV when PO route is not feasible PO: Antacids should be given at least 2 hr after folic acid; folic acid should be given 2 hr before or 46 hr after cholestyramine. A 50mcg/mL oral solution may be extemporaneously prepared by pharmacy for use in neonates and infants IV: Solution ranges from yellow to orange-yellow in color IV Adminstration: Direct IV: Diluent: Dilute with dextrose or 0.9%NaCl Concentration: 0.1 mg/mL Rate: 5 mg/min Continuous Infusion: May be added to hyperalimentation solution

Drug/generic Name Theregran (Multivitamin) Dose/route/frequency Oral/ 1 tab x day Indication Theragrans are a combination of many different vitamins that are normally found in foods and other natural sources and are used to treat vitamin deficiencies (lack of vitamins) caused by illness, pregnancy, poor nutrition, digestive disorders, and many other conditions. Patient is on this drug due chronic vitamin deficiency states resulting from colorectal cancer, chemotherapy, bleeding per colostomy, and unbalanced. Major side effects Difficulty breathing Flushing Closing of your throat Swelling of your lips, tongue, or face Hives

Drug/generic: Benadryl (Diphenhydramine) Dose/route/frequency 25mg IV Indication: Antihistamine Diphenhydramine hydrochloride is an antihistamine with anticholinergic (drying) and sedative side effects. Antihistamines appear to compete with histamine for cell receptor sites on effector cells. Used to thwart a minor allergic reaction, ie: febrile non-hemolytic reaction. Patient is on this drug due to blood transfusion therapy.

Major side effects dry mouth, nose, and throat, drowsiness, dizziness, nausea, vomiting, loss of appetite, constipation, increased chest congestion, headache, muscle weakness, ,nervousness

Drug/generic Name Aspirin Dose/route/frequency 325mg/Oral/1 x day Indication Used to reduce swelling, redness, pain, and fever, caused by various problems such as arthritis, infections, and headaches, it inhibits antiplatelet aggregation. In some cases, a physician will prescribe aspirin as a method for treating gout. Aspirin can prevent blood clots as well as a stroke or heart attack and is used as a fibrinolytic agent. Patient is on this drug to reduce pain, and prevent blood clots or stroke due to blood product transfusion. Major side effects Stomachache Heartburn Loss of appetite Small amounts of blood in stools

Drug/generic Name: Tylenol (Acetaminophen) Dose/route/frequency 15 mg/kg IV /every 6 hours/day Indications For relieving pain, reducing fever, and relieving the symptoms of allergies, cold, cough, and flu. The active ingredient is marketed as an analgesic and antipyretic. Patient is on this medication to help reduce fever related to blood transfusion.

Major side effects Paracetamol may cause allergic reactions and skin rash, wheals and may be accompanied by fever and involvement of the mucous membranes. The use of paracetamol has been associated with the occurrence of neutropenia, pancytopenia and leucopenia.