Assessment Nursing Scientific Planning Nursing Rationale Evaluation

Diagnosis Rationale Interventions

Subjective Activity A patient who After 8 hours of Independent: 1. Promotes After 8 hours
Cues: Intolerance has undergone nursing 1. Assess patient’s adequate rest, of nursing
“Nahihilo at related to blood intervention, the ability to perform maintains energy intervention,
nanghihina imbalance transfusion is patient will: normal tasks/ ADLs level and goal was
ako.” as between oxygen usually under *demonstrate a noting reports of alleviates strain on partially met
verbalized by supply/ delivery bed rest for a decrease in weakness, fatigue cardiac and as evidenced
the patient. and demand as few days that physiological and difficulty in respiratory by decreased
evidenced by: may hinder her signs of accomplishing tasks. rhythm. BP: 120/80
Objective Cues: *Body to perform her intolerance e.g. RR: 20 bpm
*BP: 130/80 weakness and usual activity. pulse, 2. Monitor BP, pulse, 2. To note PR: 79 bpm
RR: 21 bpm fatigue with Pain may also respiration and respiration during significant *reported
PR: 75 bpm report of be present and BP remain and after activity. changes that may increase
*Hgb: 97 L decreased also inhibits the within patient’s be brought about activity
Hct: 0.29 L exercise activity client to normal range. 3. Recommend quiet by the disease. tolerance
* Conscious tolerance possible ranges *report an atmosphere, bed rest including
and coherent *Increase BP of motion. And increase in if indicated. 3. Enhances rest ADLs.
* c presence of *Decrease Hgb due to decrease activity to lower body’s
body weakness and Hct levels Hgb level, tolerance 4. Elevate head of oxygen After 5 days
and fatigue which is the including ADLs. bed as tolerated and requirements of nursing
*Restlessness oxygen carrier encourage deep reducing body interventions,
* Poor appetite; in the blood, After 5 days of breathing exercise. weakness. goal was
consumed ¼ of transportation nursing partially met
the food served of oxygen to interventions, 5. Provide/ 4. Enhances lung as evidenced
* Limited ROM tissue was the patient will: recommend expansion to by increased
*Ambulatory impaired and *display an assistance with maximize Hgb: 110
with assistance hypoxia acceptable range activities/ambulation oxygenation for Hct: 0.35
develops thus of laboratory if necessary. cellular uptake. *be free from
client will values of Hgb weakness and
experience and Hct. Collaborative: 5. Although help risk of
fatigue or *be free from 6. Monitor may be necessary, complication
weakness. weakness and laboratory studies of self-esteem is is prevented.
risk of Hbg and Hct levels. enhanced when
complication is patient does things
prevented. 7. Provide oxygen as for self.
needed.
6. Identifies
8. Whole blood/ deficiencies in
packed RBC’s RBC components
(PRCs) blood affecting oxygen
products as transport and
indicated. Monitor treatment
closely for needs/response to
transfusion reactions. therapy.

7. Maximizing
oxygen transport
to tissues
improves ability
to function.

8. Increase # of
oxygen carrying
cells; corrects
deficiencies to
reduce risks of
hemorrhage in
acutely
compromised
individuals.
Assessment Diagnosis Scientific Planning Nursing Rationale Evaluation
Rationale Interventions
Subjective Nutrition After After 8 hours of Independent: 1. Monitor After 8 hours of
Cues: Imbalanced less transfusion, the nursing 1. Observe and caloric intake or nursing
“Wala akong than body body needs interventions, record patient’s food insufficient interventions,
ganang kumain requirements extra calories the patient will: intake. quality of food goal was met as
at mabilis akong related to and protein for *have good consumption. evidenced by
mapagod.” as deficiency of fast recovery. appetite: 2. Weight good appetite:
verbalized by absorbing At this time, consumed 2/4 of periodically as 2.Monitor consumed 2/4 of
the patient nutrients many people the food served. appropriate. weight loss and the food served.
necessary for experienced effectiveness of
Objective Cues: the formation of some pain and 3. Recommend nutritional After 5 days of
*Weight: 53 kg normal RBC’s fatigue. The After 5 days of small frequent meals interventions nursing
* c presence of as evidenced by: body's ability to nursing and/or between meal interventions,
body weakness * sudden weight use nutrients interventions, nourishment. 3. May reduce goal was
and fatigue loss may also be the patient will: fatigue and thus partially met as
*nausea *poor appetite; changed due to *demonstrate 4. Advised to eat enhance intake. evidenced by
*Restlessness consumed ¼ of the effects of stable weight food rich in *patient’s
* Poor appetite; the food served blood with normal carbohydrates such 4. To regain current weight
consumed ¼ of *decreased transfusion. laboratory is 55 kg.
as soft rice or bread. strength and
the food served tolerance for values. energy. *demonstrate
*Iron activity, *report absence stable weight
supplement: weakness and of nausea, with normal
Collaborative: 5. Enhance
Hemarate FA fatigue increased laboratory
5. Encourage good appetite and oral
appetite and be values.
oral care. intake.
able to relieve *report absence
Diminishes
body weakness of nausea,
6. Monitor bacterial growth
and regain increased
laboratory results minimizing
strength. appetite and be
e.g. Hbg/Hct, BUN, possibility of
able to relieve
iron, vitamin B12, infection
body weakness
folic acid, and and regain
electrolytes. 6. Replacements
strength.
needed depend
7. Administer on type of
medications as anemia and/or
indicated. Vitamin presence of poor
and mineral oral intake and
supplements e.g. identified
Vitamin B12, folic deficiencies
acid and vitamin C
7. May be
beneficial in
some types of
iron deficiency
anemia.
Assessment Diagnosis Scientific Planning Nursing Rationale Evaluation
Rationale Interventions
Subjective Cues: Risk for The skin is the After 8 hours of Independent 1. Prevents cross After 8 hours of
∅ infection related first line of nursing 1. Proper hand contamination/ nursing
to invasive defense against intervention, the washing. bacterial intervention,
Objective Cues: procedure infection. Any patient will: colonization. goal was met as
*Blood break in its *maintained 2. Maintain strict evidenced by
transfusion continuity will normal range of aseptic technique 2. Reduce risk of temperature at
*c plain NSS 1L allow temperature. with procedures. bacterial normal range.
@ 900 cc level microorganisms *be able to colonization/ *be able to
*T: 37 C to enter the verbalize 3. Encourage infection. verbalize
*Platelet Count: body, which in understanding of frequent position understanding of
307 mm3 turn can cause health teachings changes/ 3. Promotes health teachings
*c presence of infection. provided to ambulation/ ventilation of all provided to
body weakness Invasive prevent spread coughing and lungs segments prevent spread of
and fatigue procedures may of infection. deep breathing and aids in infection.
*pallor contribute to the exercise. mobilizing
development of After 4 days of secretions to After 4 days of
future infections. nursing 4. Promote prevent nursing
interventions, adequate fluid pneumonia. interventions,
the patient will: intake. goal was met as
*be able to 4. It supports evidenced by
exhibit decrease 5. Monitor circulating *patient
risk for spread of temperature. volume and exhibited
infection. Note presence of tissue perfusion decrease risk for
chills and and it aids in the spread of
tachypnea with elimination of infection.
or without fever. microorganisms
that may
contribute to the
occurrence of
infection.
5. To note for
progress and
evaluate for risk
of infection
Assessment Diagnosis Scientific Planning Nursing Rationale Evaluation
Rationale Interventions
Subjective Knowledge Presence of After 8 hours of Independent: 1. Provides After 8 hours of
Cues: deficit regarding knowledge nursing 1. Provide knowledge base nursing
“Kapag natapos condition, deficit is due to interventions, information from which patient intervention,
na ba ang prognosis, some unfamiliar the patient will: about anemia can make informed goal was met as
pagsalin ng treatment, self information that * verbalize and explain that choices. Allays evidenced by
dugo, magiging care and causes understanding of therapy depends anxiety and may *patient
maayos na ba discharge needs confusion to the the nature of the on the type and promote verbalized
ako.” as related to lack of patient that process, severity of the cooperation with understanding
verbalized by exposure/recall needs to be diagnostic anemia. therapeutics of the process,
the patient information and discussed and procedures and regimen. diagnostic
unfamiliarity clarified. potential 2. Explain that procedures and
Objective Cues: with information complication of blood taken for 2. This is often an, potential
*c presence of measures blood laboratory unspoken concern complication of
body weakness transfusion. studies will not that can potentiate blood
and fatigue *verbalize worsen anemia. patient’s anxiety. transfusion.
*Restlessness understanding of * Verbalized
*Inaccurate therapeutic 3. Encourage 3. Smoking understanding
follow-through needs. cessation of decreases available of therapeutic
of instruction smoking. oxygen and causes need
After 5 days of vasoconstriction
nursing After 5 days of
interventions, 4. Provide 4. Information nursing
the patient will: information enhances interventions,
*verbalize about purpose, cooperation with
goal was met as
understanding of dosage, regimen. Recovery
evidenced by
disease process, schedule, from anemia can be
precautions and slow, requiring patient
prognosis, and
adverse reaction lengthy treatment verbalized
potential to all prescribed and prevention of understanding
complications. medications. secondary of disease
complications. process,
6. Discuss the 6. Iron supplements prognosis, and
importance of usually take 3- potential
taking oral iron 6mos. complications.
preparation.
7. Decreased
7. Discuss leukocyte
increased production
susceptibility to potentiates risk of
infections, signs infection.
and symptoms
requiring
medical
intervention e.g.
fever.
Assessment Diagnosis Scientific Planning Nursing Rationale Evaluation
Rationale Interventions
Subjective Cues: Anxiety related Anxiety is a After 8 hours of Independent: After 8 hours of
“Kinakabahan to impending normal nursing 1. Monitor Vital 1. To obtain nursing
ako sa mga blood experience. interventions, Signs. baseline data. interventions,
gagawin sakin.” transfusion Moderate or the patient will: goal was met as
as verbalized by high level of *enumerate 2. Assess level 2. Identify areas evidenced by
the patient. anxiety can different of anxiety of concern that *patient
increase methods of through verbal might interfere enumerated
Objective Cues: alertness and relaxation and nonverbal with the normal different
*Exhibit poor performance in techniques. cues. progress of methods of
eye contact particular *absence of blood relaxation
*Facial tension situations. facial tension 3. Employ a transfusion. techniques e.g.
observed However, people and improved calm, caring, deep breathing
*Short attention who experience attention span. confident, and 3. Enhances exercise and
span continues or *verbalizes non-judgmental nurse/ patient listening to
recurring fears control of the approach. relationship. music.
or episodes of situation
intense fear can 4. Allow patient 4. Provides a *absence of
feel powerless to After 3 days of to express fears healthy outlet of facial tension
manage their nursing and feelings of emotions and and improved
symptoms and interventions, anxiety relieves anxiety. attention span.
their lives can the patient will appropriately. *verbalized
become severely be able to: 5. Environmental control of the
restricted. *express 5. Provide a changes may situation
decreased level quiet, calm lessen the
of anxiety as environment. patient’s anxiety. After 3 days of
evidenced by the nursing
patient appearing 6. Encourage 6. A feeling of interventions,
rested and relax. the use of self control & goal was met as
breathing success in evidenced by
retraining & facilitating *patient
relaxation breathing helps expressed
techniques. reduce anxiety. decreased level
of anxiety as
7. Acknowledge 7. Adequate evidenced by the
normality of fear explanation patient appearing
and provide helps reduce rested and relax.
opportunity for anxiety, soothe
questions and fears, and
answer honestly provides
within client’s assurance.
level of
understanding.

Collaborative
1. Refer to 1. Provides
support groups ongoing and
as needed. timely support.