ASSESSMENT Irritability Pallor on face and fingers on both extremities V/S: T – 36.5 ºC P – 129 bpm R – 58 breaths/min Lab tests: Hb – 68 gm/L HCT – 0.23% RBC – 2.91 x 1012/L
DIAGNOSIS Impaired Gas Exchange related to low RBC count as evidenced by pallor on the face and fingers, and dyspnea
PLANNING General: - To facilitate the maintenance of oxygen to all body cells
INTERVENTION Independent:
RATIONALE
Assess patient’s respirations: Rate, rhythm, depth and and breathing effort
This will serve as indicators of respiratory function and assess the therapy needed by the patient
After 1 day of effective nursing interventions the patient will be able to:
Monitor vital signs, note for changes in cardiac rhythm
Hypoxia is associated with signs of increased breathing effort
1. Display laboratory values within acceptable range
Recommend quiet atmosphere and bed rest if indicated
This enhances rest to lower body’s oxygen requirements and reduces strain on the heart and lungs .
Recommend mother to stimulate the baby to cry once in a while
Enhances lung expansion to maximize oxygenation for cellular uptake.
2. Manifest glow on the face and return of color on the fingers
Collaborative: Monitor Hb levels
Low Hb levels reduce the uptake of oxygen at the alveolar capillary membrane and oxygen delivery to tissues
Administer packed RBCs or exchange transfusions as indicated
This increases number of oxygen-carrying cells, improve circulation. PRBCs are used because they are less likely to create circulatory overload
Administer meds as indicated: - Ferlin i ml BID -Folic Acid 5 mg i tab BID -Fortum 270 mg IV q2H NST
Drug therapy helps to increase haemoglobin levels and promote maximum potential of wellness
EVALUATION After the whole stay of the patient in the ICU, patient was able to achieved: Increase hemoglobin level after blood transfusion Return of pinkish color on both hands and face