NURSING DIAGNOSIS INTERVENTIONS RATIONALE EVALUATION Activity Intolerance related to Imbalance between oxygen supply or delivery and demand

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Assess patient ability to perform ADLs Monitor vital sign (Blood Pressure, pulse, and respirations) during and after activity Suggest client change position slowly; monitor for dizziness. Provide or recommend assistance with activities and ambulation as necessary, allowing client to be an active participant as much as possible. Identify and implement energy-saving techniques Instruct client to stop activity if palpitations, chest pain, shortness of breath, weakness, or dizziness occur

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Collaborative
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Monitor laboratory studies, such as Hgb/Hct, RBC count, and arterial blood gases (ABGs). Provide supplemental oxygen as indicated. Administer the following, as indicated: Whole blood, packed RBCs (PRCs); blood products as indicated. Monitor closely for transfusion reactions. Prepare for surgical intervention, if indicated. Influences choice of interventions and needed assistance. Cardiopulmonary manifestations result from attempts by the heart and lungs to supply adequate amounts of oxygen to the tissues. Postural hypotension or cerebral hypoxia may cause dizziness, fainting, and increased risk of injury. Although help may be necessary, self-esteem is enhanced when client does some things for self. Encourages client to do as much as possible, while conserving limited energy and preventing fatigue.

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Cellular ischemia potentiates risk of infarction, and excessive cardiopulmonary strain and stress may lead to decompensation and failure Identifies deficiencies in RBC components affecting oxygen transport, treatment needs, and response to therapy. Maximizing oxygen transport to tissues improves ability to function Increases number of oxygen-carrying cells; corrects deficiencies to reduce risk of hemorrhage in acutely compromised individuals. Surgery is useful to control bleeding in clients who are anemic because of bleeding, such as in ulcers and uterine bleeding; or to remove spleen as treatment of autoimmune hemolytic anemia. Bone marrow and stem cell transplantation may be done in presence of bone marrow failure aplastic anemia.

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Report an increase in activity tolerance, including ADLs. Demonstrate a decrease in physiological signs of intolerance pulse, respirations, and BP remain within clients normal range. Display laboratory values (Hgb/Hct) within acceptable range.