Wednesday, January 16, 2013

Ineffective Tissue Perfusion related to Anemia

9/10 3698


Nursing Diagnosis for Anemia: Impaired Tissue Perfusion

Definition: Decrease in oxygen resulting in damage to tissue maintenance.

Defining characteristics:
1. Cardiopulmonary
  • Changes in respiratory frequency
  • The use of additional respiratory muscles
  • Abnormal blood gas analysis
  • Dyspnea
  • Arrhythmias
  • Chest pain
  • Chest retraction
  • Capilary refill more than 3 seconds
  • Bronchospasm
2. Peripheral
  • Edema
  • Changes in skin characteristics
  • Changes in skin temperature
  • Bluish
  • Impaired sensation
  • Cold extremities
  • Wound healing is a long
3. Gastrointestinal
  • Voice intestinal hipoaktif
  • Nausea
  • Abdominal distention
  • Abdominal pain
4. Renal
  • Changes in blood pressure
  • Hematuria
  • Oliguria
  • Increased BUN and creatinine
5. Cerebral
  • Abnormal speech
  • Weakness of the extremities
  • Changes in mental status
  • Changes in pupil reaction
  • Difficulty swallowing
  • Changes in motor response
Related factors:
  • Decrease in hemoglobin in the blood

Diagnosis, Goals, Outcomes, Nursing Interventions:

Nursing Management of Low Back PainDefinition of Low Back Pain

Low Back Pain (LBP) or lower back pain is a sensation of pain that is felt in the intervertebral discs, are generally lower lumbar, L4-L5 and L5-S1.

Etiology of Low Back Pain

Most lower back pain caused by any of a variety of musculoskeletal problems (eg, acute lumbosacral strain, lumbosacral ligament instability and muscle weakness, osteoarthritis spine, spinal stenosis, intervertebral disc problems, leg length inequality). Other causes include obesity, kidney disorders, pelvic problems, retroperitoneal tumors, abdominal aneurysms and psychosomatic problems. Most back pain due to musculoskeletal disorders will be aggravated by activity, whereas the pain due to other circumstances is not affected by the activity.

Clinical Manifestations of Low Back Pain

Patients usually complain of back pain is acute or chronic back pain and weakness. During the initial interview, review the location of pain, its nature and how to spread along nerve fibers (sciatica), also evaluated the patient's gait, mobility of the spine, reflexes, leg length, motor strength and sensory perception along with the degree of discomfort. Straight leg raising in the circumstances that resulted in pain suggests irritation of nerve fibers.

Physical examination can be found, the para-vertebral muscle spasm (increased postural muscle tone back the excessive bone) with loss of normal lumbar curvature lordotik and there may be deformity of the spine. If the patient is examined in a state of stomach, paraspinal muscles will relax and deformity caused by a spasm will disappear.

Sometimes the organic basis of back pain can not be found. Anxiety and stress can evoke muscle spasm and pain. Lower back pain can be a manifestation of depression or mental conflict or reaction to environmental stressors and life. When we examined patients with low back pain, nurses need to revisit the family relationships, environment and work situation variables.

Nursing Management of Low Back Pain

Most back pain can go away and will heal in 6 weeks with bed rest, stress reduction and relaxation. The patient must remain in bed with a mattress that padatl for 2 to 3 days. The position of the patient are such that the larger lumbar flexion which may reduce pressure on spinal nerve fibers. The head of the bed elevated 30 degrees and the patient slightly flexed knees or lying on her side with Lutu and pelvis and legs bent and a pillow placed under the head. The prone position be avoided because it will aggravate the lordosis. Sometimes patients need to be admitted to the handling of "active conservative" and physiotherapy. Intermittent pelvic traction with 7 to 13 kg load traction. Traction allows the addition of lumbar flexion and muscle relaxation.

Physiotherapy should be given to reduce pain and muscle spasms. Therapy may include cooling (eg with ice), infrared heating, moist compresses and hot, turbulent pool and traction. Circulatory disorders, trauma disorders, and touching a hot compress is contraindicated. Turbulent pool therapy is contraindicated for patients with cardiovascular problems due to inability to tolerate the resulting massive peripheral vasodilatation. Ultra heat wave will lead to increased discomfort due to swelling in the acute stage.
Medications may be needed to treat acute pain.
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