Conditions Affecting Tissue Perfusion

  1. Iron deficiency anemia (hypochromic microcytic anemia): inadequate production of red blood cells due to lack of heme (iron); common in infants, pregnant women, and premenopausal women.
    1. Pathophysiology: decreased dietary intake, impaired absorption, or increased utilization of iron decreases the amount of iron bound to plasma transferrin and transported to bone marrow for hemoglobin synthesis; decreased hemoglobin in erythrocytes decreases amount of oxygen delivered to tissues.
    2. Risk factors:
      1. Excessive menstruation.
      2. Gastrointestinal bleeding - peptic ulcer, hookworm, tumors.
      3. Inadequate diet - anorexia, fad diets, cultural practices.
      4. Poor absorption - stomach, small intestine disease.
    3. Assessment:
      1. Subjective data
        1. Fatigue: increasing.
        2. Headache.
        3. Change in appetite; difficulty swallowing due to pharyngeal edema/ulceration; heartburn.
        4. Shortness of breath on exercise.
        5. Extremities: numb, tingling.
        6. Flatulence.
        7. Menorrhagia.
      2. Objective data
        1. Vital signs:
          1. BP - increased systolic, widened pulse pressure.
          2. Pulse - tachycardia.
          3. Respirations - tachypnea.
          4. Temperature - normal or subnormal.
        2. Skin/mucous membranes: pale, dry; tongue - smooth, shiny, bright red; cheilosis (cracked, painful corners of mouth).
        3. Sclera: pearly white.
        4. Nails: brittle, spoon shaped, flattened.
        5. e. Lab data: decreased - hemoglobin (<10 g/dL blood), serum iron (<65 p.g/dL blood); increased total iron-binding capacity.
    4. Analysis/nursing diagnosis:
      1. Altered nutrition, less than body requirements, related to inadequate iron absorption.
      2. Altered tissue perfusion related to reduction in red cells.
      3. Risk for activity intolerance related to profound weakness.
      4. Impaired gas exchange related to decreased oxygen-carrying capacity.
    5. Nursing care plan/implementation:
      1. Goal: promote physical and mental equilibrium.
        1. Position: optimal for respiratory excursion; deep breathing; turn frequently to prevent skin breakdown.
        2. Rest: balance with activity, as tolerated; assist with ambulation.
        3. O c. Medication (hematinics):
          1. Oral iron therapy (ferrous sulfate) - give with meals.
          2. Intramuscular therapy (iron dextran) - use second needle for injection after withdrawal from ampule; use Z-track method; inject 0.5 mL of air before withdrawing needle, to prevent tissue necrosis; use 2 to 3 inch needle; rotate sites; do not rub site or allow wearing of constricting garments after injection.
        4. Keep warm: no hot water bottles, heating pads, due to decreased sensitivity.
        5. Diet: high in protein, iron, vitamins; assistance with feeding, if needed; nonirritating foods with mouth or tongue soreness.
      2. Goal: health teaching.
        1. Dietary regimen.
        2. Iron therapy: explain purpose, dosage, side effects (black or green stools, constipation, diarrhea); take with meals.
        3. Activity: exercise to tolerance, with planned rest periods.
    6. Evaluation/outcome criteria:
      1. Hemoglobin and hematocrit level return to normal range.
      2. Tolerates activity without fatigue.
      3. Selects foods appropriate for dietary regimen.

  2. Hemolytic anemia (normocytic normochromic anemia): premature destruction (hemolysis) of erythrocytes; occurs extravascularly (autoimmune) or intravascularly (dialysis, heart valves).
    1. Risk factors - autoimmune hemolytic anemia:
      1. Warm reacting: women, lupus, rheumatoid arthritis, myeloma.
      2. Cold reacting (e.g., Raynaud’s): older women, Epstein-Barr virus.
      3. Drug induced: methyldopa, penicillin, quinine.
    2. Assessment:
      1. Subjective data
        1. Fatigue; physical weakness.
        2. Dizziness.
        3. Shortness of breath.
        4. Diaphoresis on slight exertion.
      2. Objective data
        1. Skin: pallor, jaundice.
        2. Posture: drooping.
        3. Lab data:
          1. Decreased hematocrit.
          2. Increased reticulocyte count; bilirubin.
          3. Direct Coombs’ test positive.

  3. Pernicious anemia (megaloblastic macrocytic anemia): lack of intrinsic factor found in gastric mucosa, which is necessary for vitamin Bl2 (extrinsic factor) absorption; slow developing, usually after age 50; may be an autoimmune disorder.
    1. Pathophysiology: atrophy or surgical removal of glandular mucosa in fundus of stomach —> degenerative changes in brain, spinal cord, and peripheral nerves from lack of vitamin B12.
    2. Risk factors:
      1. Partial or complete gastric resection.
      2. Prolonged iron deficiency; veganism.
      3. Heredity.
    3. Assessment:
      1. Subjective data
        1. Hands, feet: tingling, numbness.
        2. Weakness, fatigue.
        3. Sore tongue, anorexia.
        4. Difficulties with memory, balance.
        5. Irritability, mild depression.
        6. Shortness of breath.
        7. Palpitations.
      2. Objective data
        1. Skin: pale, flabby, jaundiced.
        2. Sclera: icterus (yellow).
        3. Tongue: smooth, glossy, red, swollen.
        4. Vital signs:
          1. BP - normal or elevated.
          2. Puke - tachycardia.
        5. Nervous system:
          1. Decreased vibratory sense in lower extremities.
          2. Loss of coordination.
          3. Babinski present (flaring of toes with stimulation of sole of foot).
          4. Positive Romberg (loses balance when eyes closed).
          5. Increased or diminished reflexes.
        6. Lab data: decreased hemoglobin, RBCs, platelets, gastric secretions (achlorhydria), Schilling test (radioactive vitamin B12 urine test).
    4. Analysis/nursing diagnosis:
      1. Altered nutrition, less than body requirements, related to B12 deficiency.
      2. Impaired physical mobility related to numbness of extremities.
      3. Fatigue related to decreased oxygen-carrying capacity.
      4. Altered oral mucous membrane related to changes in gastric mucosa.
      5. Altered thought processes related to progressive neurological degeneration.
    5. Nursing care plan/implementation:
      1. Goal: promote physical and emotional comfort.
        1. Activity: bed rest or activity as tolerated - restrictions depend on neurological or cardiac involvement.
        2. Comfort: keep extremities warm - light blankets, loose-fitting socks.
        3. Medication: vitamin B12 therapy as ordered.
        4. Diet:
          1. Six small feedings.
          2. Soft or pureed.
          3. Organ meats, fish, eggs.
          4. e. Mouth care: before and after meals, to increase appetite and relieve mouth discomfort.
      2. Goal: health teaching.
        1. Medication:
          1. Lifelong therapy.
          2. Injection techniques; rotation of sites.
        2. Diet.
        3. Rest; exercise to tolerance.
    6. Evaluation/outcome criteria:
      1. No irreversible neurological or cardiac complications.
      2. Takes vitamin B12 for the rest of life - uses safe injection technique.
      3. Returns for follow-up care.
  1. Polycythemia vera: abnormal increase in circulating red blood cells (myeloproliferative disorder); considered to be a form of malignancy; occurs more frequently among middle-aged Jewish men.
    1. Pathophysiology: unknown causes —> massive increases of erythrocytes, myelocytes (bone marrow leukocytes), and thrombocytes —» increased blood viscosity/volume and tissue/organ congestion; increased peripheral vascular resistance; intravascular thrombosis usually develops in middle age, particularly in Jewish men; in contrast, secondary polycythemia occurs as a compensatory response to tissue hypoxia associated with prolonged exposure to high altitude, chronic lung disease, and heart disease.
    2. Assessment:
      1. Subjective data
        1. Headache; dizziness; ringing in ears.
        2. Weakness; loss of interest.
        3. Feelings of abdominal fullness.
        4. Shortness of breath; orthopnea.
        5. Pruritus, especially after bathing.
        6. Pain: gouty-arthritic.
      2. Objective data
        1. Skin: mucosal erythema, ruddy complexion (reddish purple).
        2. Ecchymosis; gingival (gum) bleeding.
        3. Enlarged liver, spleen.
        4. Hypertension.
        5. Lab data:
          1. Increased - hemoglobin, hematocrit, RBCs, leukocytes, platelets, uric acid.
          2. Decreased bone marrow iron.
    3. Analysis/nursing diagnosis:
      1. Altered tissue perfusion related to capillary congestion.
      2. Risk for injury related to dizziness, weakness.
      3. Fluid volume excess related to mass production of red blood cells.
      4. Risk for impaired skin integrity related to pruritus.
      5. Ineffective breathing pattern related to shortness of breath, orthopnea.
    4. Nursing care plan/implementation:
      1. Goal: promote comfort and prevent complications.
        1. Observe for signs of bleeding, thrombosis - stools, urine, gums, skin, ecchymosis.
        2. Reduce occurrence: avoid prolonged sitting, knee gatch.
        3. Assist with ambulation.
        4. B d. Position: elevate head of bed.
        5. Skin care: cool-water baths to decrease pruritus; may add bicarbonate of soda to water.
        6. Fluids: force, to reduce blood viscosity and promote urine excretion; 1500-2500 mL/24 hours.
        7. Diet: avoid foods high in iron, to reduce RBC production.
        8. Assist with venesection (phlebotomy), as ordered; 350-500 mL blood every other day until Het low normal.
      2. Goal: health teaching.
        1. Ml a. Diet: foods to avoid (e.g., liver, egg yolks); fluids to be increased.
        2. Signs/symptoms of complications: infections, hemorrhage.
        3. Avoid: falls, bumps; hot baths/showers (worsens pruritus).
        4. Drugs: myelosuppressive agents (busulfan [Myleran], cyclophosphamide [Cytoxan], chlorambucil, radioactive phosphorus); purpose; side effects.
        5. Procedures: venesection (phlebotomy) if ordered.
    5. Evaluation/outcome criteria:
      1. Acceptance of chronic disease.
      2. Reports at prescribed intervals for follow-up.
      3. Remission: reduction of bone marrow activity, blood volume and viscosity (RBC <6,500,000/p.L; Hgb <18 g/dL; Het <45%; WBC <10,000/p,L).
      4. No complications (e.g., thrombi, hemorrhage, gout, CHF, leukemia).
  1. Leukemia (acute and chronic): a neoplastic disease involving the leukopoietic tissue in either the bone marrow or lymphoid areas; acute leukemia occurs in children, young adults; chronic forms occur in later adult life.
    1. Types:
      1. Acute nonlymphocytic (ANLL) - also known as acute myelogenous leukemia (AML); seen generally in older age (>60 years).
      2. Acute lymphoblastic (ALL) - common in children 2-10 years.
      3. Chronic lymphocytic (CLL) - generally affects the elderly.
      4. Chronic myelogenous (CML) - also known as chronic granulocytie leukemia (CGL); more likely to occur between 25 and 60 years.
    2. Pathophysiology: displacement of normal marrow cells by proliferating leukemic cells (abnormal, immature leukocytes) —» normochromic anemia, thrombocytopenia.
    3. Risk factors:
      1. Viruses.
      2. Genetic abnormalities.
      3. Exposure to chemicals.
      4. Radiation.
      5. Treatment for other types of cancer (e.g., alkylating agents).
    4. Assessment:
      1. Subjective data
        1. Fatigue, weakness.
        2. Anorexia, nausea.
        3. Pain: joints, bones (acute leukemia).
        4. Night sweats, weight loss, malaise.
      2. Objective data
        1. Skin: pallor due to anemia; jaundice.
        2. Fever: frequent infections; mouth ulcers.
        3. Bleeding: petechiae, purpura, ecchymosis, epistaxis, gingiva.
        4. Organ enlargement: spleen, liver.
        5. Enlarged lymph nodes; tenderness.
        6. Bone marrow aspiration: increased presence of blasts.
        7. Lab data:
          1. WBC - 15000->100000/p.L
          2. RBC - normal to severely decreased.
          3. Hgb - low or normal.
          4. Platelets - low to elevated.
    5. Analysis/nursing diagnosis:
      1. Risk for infection related to immature or abnormal leukocytes.
      2. Activity intolerance related to hypoxia and weakness.
      3. Fatigue related to anemia.
      4. Altered tissue perfusion related to anemia.
      5. Anxiety related to diagnosis and treatment.
      6. Altered oral mucous membrane related to susceptibility to infection.
      7. Fear related to diagnosis.
      8. Ineffective individual or family coping related to potentially fatal disease.
    6. Nursing care plan/implementation:
      1. Goal: prevent, control, and treat infection.
        1. Protective isolation if indicated.
        2. Observe for early signs of infection:
          1. Inflammation at injection sites.
          2. Vital-sign changes.
          3. Cough.
          4. Obtain cultures.
        3. Give antibiotics as ordered.
        4. Mouth care: clean q2h, examine for new lesions, avoid trauma.
      2. Goal: assess and control bleeding, anemia.
        1. Activity: restrict to prevent trauma.
        2. Observe for hemorrhage: vital signs; body orifices, stool, urine.
        3. Control localized bleeding: ice, pressure at least 3-4 minutes after needle sticks, positioning.
        4. Use soft-bristle or foam-rubber toothbrush to prevent gingival bleeding.
        5. Give blood/blood components as ordered; observe for transfusion reactions.
      3. Goal: provide rest, comfort, nutrition.
        1. Activity: 8 hours sleep or rest; daily nap.
        2. Comfort measures: flotation mattress, bed cradle, sheepskin.
        3. Analgesics: without delay.
          1. Mild pain (acetaminophen [Tylenol], propoxyphene HCl [Darvon] without aspirin).
          2. Severe pain (codeine, meperidine HC1 [Demerol]).
        4. Diet: bland.
          1. High in protein, minerals, vitamins.
          2. low roughage.
          3. Small, frequent feedings.
          4. Favorite foods.
        5. Fluids: 3000-4000 mL/day.
      4. Goal: reduce side effects from therapeutic regimen.
        1. Nausea: antiemetics, usually half-hour before chemotherapy.
        2. Increased uric acid level: force fluids.
        3. De. Stomatitis: antiseptic anesthetic mouthwashes.
        4. Rectal irritation: meticulous toileting, sitz baths, topical relief (e.g., Tucks).
      5. Goal: provide emotional/spiritual support.
        1. Contact clergy if patient desires.
        2. Allow, encourage patient-initiated discussion of death (developmentally appropriate).
        3. Allow family to be involved in care.
        4. If death occurs, provide privacy, listening, sharing of grief for family.
      6. Goal: health teaching.
        1. Prevent infection.
        2. Limit activity.
        3. Control bleeding.
        4. Reduce nausea.
        5. Mouth care.
        6. Chemotherapy: regimen; side effects.
    7. Evaluation/outcome criteria:
      1. Alleviate symptoms; obtain remission.
      2. Prevent complications (e.g., infection).
      3. Ventilates emotions - accepts and deals with anger.
      4. Experiences peaceful death (e.g., pain free).
  1. Idiopathic thrombocytopenic purpura (ITP): potentially fatal disorder characterized by spontaneous increase in platelet destruction; possible autoimmune response; seen predominantly in 2 to 4 years old and girls/women 10 years old. Remissions occur spontaneously or following splenectomy; in contrast, secondary thrombocytopenia is caused by viral infections, drug hypersensitivity (i.e., quinidine, sulfonamides), lupus, or bone marrow failure; treat cause.
    1. Assessment:
      1. Subjective data
        1. Spontaneous skin hemorrhages - lower extremities.
        2. Menorrhagia.
        3. Epistaxis.
      2. Objective data
        1. Bleeding: GI, urinary, nasal; following minor trauma, dental extractions.
        2. Petechiae; ecchymosis.
        3. Tourniquet test - positive, demonstrating increased capillary fragility.
        4. Lab data:
          1. Decreased platelets (< 100,000/p.L).
          2. Increased bleeding time.
    2. Analysis/nursing diagnosis:
      1. Risk for injury related to hemorrhage.
      2. Altered tissue perfusion related to fragile capillaries.
      3. Impaired skin integrity related to skin hemorrhages.
    3. Nursing care plan/implementation:
      1. Goal: prevent complications from bleeding tendencies.
        1. Precautions:
          1. Injections - use small-bore needles; rotate sites; apply direct pressure.
          2. Avoid bumping, trauma.
          3. Use swabs for mouth care.
        2. Observe for signs of bleeding, petechiae following blood pressure reading, ecchymosis, purpura.
        3. Administer steroids (e.g., prednisone) with ITP to increase platelet count; give platelets for count below 20,000-30,000/ p.L with STP; high-dose immunoglobulins.
      2. Goal: health teaching.
        1. Avoid traumatic activities:
          1. Contact sports.
          2. Violent sneezing, coughing, nose blowing.
          3. Straining at stool.
          4. Heavy lifting.
        2. Signs of decreased platelets - petechiae, ecchymosis, gingival bleeding, hematuria, menorrhagia.
        3. Use Medic Alert tag/card.
        4. Precautions: self-medication; particularly avoid aspirin-containing drugs.
        5. Prepare for splenectomy if drug therapy unsuccessful (prednisone, cyclophosphamide, azathioprine [Imuran]).
    4. Evaluation/outcome criteria:
      1. Returns for follow-up.
      2. No complications (e.g., intracranial hemorrhage).
      3. Platelet count >200,000/p.L.
      4. Skin remains intact.
      5. Resumes self-care activities.
  1. Splenectomy: removal of spleen following rupture due to acquired hemolytic anemia, trauma, tumor, or idiopathic thrombocytopenic purpura.
    1. Analysis/nursing diagnosis:
      1. Risk for fluid volume deficit related to hemorrhage.
      2. Risk for infection related to impaired immune response.
      3. Pain related to abdominal distention.
      4. Ineffective breathing pattern related to high abdominal incision.
    2. Nursing care plan/implementation:
      1. Goal: prepare for surgery.
        1. Give whole blood, as ordered.
        2. Insert nasogastric tube to decrease postoperative abdominal distention, as ordered.
      2. Goal: prevent postoperative complications.
        1. Observe for:
          1. Hemorrhage - bleeding tendency with thrombocytopenia due to decreased platelet count.
          2. Gastrointestinal distention - removal of enlarged spleen may result in distended stomach and intestines, to fill void.
        2. Recognize 101°F temp as normal for 10 days.
        3. Incision: splint when coughing, to prevent high incidence of atelectasis (common complication), pneumonia with upper-abdominal incision.
      3. Goal: health teaching.
        1. Increased risk of infection postsplenectomy.
        2. Report signs of infection immediately.
    3. Evaluation/outcome criteria:
      1. No complications (e.g., respiratory, subphrenic abscess or hematoma, thromboemboli, infection).
      2. Complete and permanent remission - occurs in 60-80% of patients.