Nursing diagnosis: risk for ineffective Protection
Risk factors may include
Abnormal blood profile—decreased RBC production and survival, altered clotting factors (suppressed erythropoietin production or secretion)
Increased capillary fragility
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Experience no signs and symptoms of bleeding or hemorrhage.
Maintain or demonstrate improvement in laboratory values.
Nursing intervention with rationale:
1. Note reports of increasing fatigue and weakness. Observe for tachycardia, pallor of skin and mucous membranes, dyspnea, and chest pain. Plan client activities to avoid fatigue.
Rationale: May reflect effects of anemia and cardiac response necessary to keep cells oxygenated.
2. Monitor level of consciousness (LOC) and behavior.
Rationale: Anemia may cause cerebral hypoxia manifested by changes in mentation, orientation, and behavioral responses.
3. Evaluate response to activity and ability to perform tasks. Assist as needed and develop schedule for rest.
Rationale: Anemia decreases tissue oxygenation and increases fatigue, which may require intervention, changes in activity, and rest.
4. Limit vascular sampling; combine laboratory tests when possible.
Rationale: Recurrent and excessive blood sampling can worsen anemia.
5. Observe for oozing from venipuncture sites, bleeding or ecchymotic areas following slight trauma, petechiae, and joint swelling or mucous membrane involvement—bleeding gums, recurrent epistaxis, hematemesis, melena, and hazy or red urine.
Rationale: Bleeding can occur easily because of capillary fragility and altered clotting functions and may worsen anemia.
6. Hematest gastrointestinal (GI) secretions and stool for blood.
Rationale: Mucosal changes and altered platelet function due to uremia may result in gastric mucosal erosion and GI hemorrhage.
7. Provide soft toothbrush and electric razor. Use smallest needle possible and apply prolonged pressure following injections or vascular punctures.
Rationale: Reduces risk of bleeding and hematoma formation.
8. Monitor laboratory studies, such as the following: RBCs, Hgb/Hct
Rationale: Uremia decreases production of erythropoietin and depresses RBC production and survival time. In CRF, Hgb and Hct are usually low, but tolerated, such as client may not be symptomatic until Hgb is below 7.
9. Administer fresh blood and packed red cells (PRCs), as indicated.
Rationale: May be necessary when client is symptomatic with anemia. PRCs are usually given when client is experiencing fluid overload or receiving dialysis treatment. Washed RBCs are used to prevent hyperkalemia associated with stored blood.
10. Administer medications, as indicated, for example: Erythropoietin preparations (Epogen, EPO, Procrit)
Rationale: Stimulates the production and maintenance of RBCs, thus decreasing the need for transfusion.