Nursing Care Plan for Pancytopenia
Aplastic anemia is a hematological disorder characterized by a decrease in peripheral blood cellular components caused by the failure of production in the bone marrow. In this situation the number of blood cells produced inadequate. Patients experiencing pancytopenia, ie a situation where there is a shortage of red blood cells, white blood cells, and platelets.
Nursing Diagnosis and Interventions for Pancytopenia
Altered Tissue Perfusion related to a decrease in cellular components required for the delivery of oxygen / nutrients to the cells.
Goal: indicates adequate perfusion
Expected outcomes:
- Vital signs are stable.
- Pink mucous membranes.
- Capillary refill.
- Adequate urine output.
1) Measure vital signs, observation capillary refill, color of skin / mucous membranes, nail beds.
R /: Provides information about the adequacy of tissue perfusion and help needs intervention.
2) Auscultation of breath sounds.
R /: Dyspnea, gurgling shows CHF as long heart strain / compensatory increase in cardiac output.
3) Observation complaints of chest pain, palpitations.
R /: Ischemia cell, affecting myocardial tissue / potential risk of infarction.
4) Evaluation slowed verbal response, agitation, memory impairment, confusion.
R /: May indicate cerebral perfusion disturbances due to hypoxia
5) Evaluation of complaints of cold, keep the ambient temperature and the body to keep warm.
R /: vasoconstriction (to vital organs) lowers peripheral circulation.
Collaboration
6) Observation results of laboratory tests Complete blood.
R /: Identify deficiencies and needs treatment / response to therapy.
7) Provide a complete blood transfusion / packed as indicated.
R /: Increase the number of oxygen-carrying cells, improve the deficiency to reduce the risk of bleeding.
8) Give oxygen as indicated.
R /: Maximizing oxygen transport to the tissues.
9) Prepare the surgical intervention as indicated.
R /: Bone marrow transplant performed on bone marrow failure / aplastic anemia.