Assessment Subjective Cues: “Nahihilo at nanghihina ako.” as verbalized by the patient.

Objective Cues: *BP: 130/80 RR: 21 bpm PR: 75 bpm *Hgb: 97 L Hct: 0.29 L * Conscious and coherent * c presence of body weakness and fatigue *Restlessness * Poor appetite; consumed ¼ of the food served * Limited ROM *Ambulatory with assistance

Nursing Diagnosis Activity Intolerance related to imbalance between oxygen supply/ delivery and demand as evidenced by: *Body weakness and fatigue with report of decreased exercise activity tolerance *Increase BP *Decrease Hgb and Hct levels

Scientific Rationale A patient who has undergone blood transfusion is usually under bed rest for a few days that may hinder her to perform her usual activity. Pain may also be present and also inhibits the client to possible ranges of motion. And due to decrease Hgb level, which is the oxygen carrier in the blood, transportation of oxygen to tissue was impaired and hypoxia develops thus client will experience fatigue or weakness.

Planning After 8 hours of nursing intervention, the patient will: *demonstrate a decrease in physiological signs of intolerance e.g. pulse, respiration and BP remain within patient’s normal range. *report an increase in activity tolerance including ADLs. After 5 days of nursing interventions, the patient will: *display an acceptable range of laboratory values of Hgb and Hct. *be free from weakness and

Nursing Interventions Independent: 1. Assess patient’s ability to perform normal tasks/ ADLs noting reports of weakness, fatigue and difficulty in accomplishing tasks.

Rationale 1. Promotes adequate rest, maintains energy level and alleviates strain on cardiac and respiratory rhythm.

Evaluation After 8 hours of nursing intervention, goal was partially met as evidenced by decreased BP: 120/80 RR: 20 bpm PR: 79 bpm *reported increase activity tolerance including ADLs. After 5 days of nursing interventions, goal was partially met as evidenced by increased Hgb: 110 Hct: 0.35 *be free from weakness and risk of complication is prevented.

2. Monitor BP, pulse, 2. To note respiration during significant and after activity. changes that may be brought about 3. Recommend quiet by the disease. atmosphere, bed rest if indicated. 3. Enhances rest to lower body’s 4. Elevate head of oxygen bed as tolerated and requirements encourage deep reducing body breathing exercise. weakness. 5. Provide/ recommend assistance with activities/ambulation if necessary. Collaborative: 6. Monitor laboratory studies of 4. Enhances lung expansion to maximize oxygenation for cellular uptake. 5. Although help may be necessary, self-esteem is

enhanced when patient does things for self. Provide oxygen as needed. corrects deficiencies to reduce risks of hemorrhage in acutely compromised individuals. Maximizing oxygen transport to tissues improves ability to function. Whole blood/ deficiencies in packed RBC’s RBC components (PRCs) blood affecting oxygen products as transport and indicated. Increase # of oxygen carrying cells.risk of complication is prevented. 7. Hbg and Hct levels. therapy. 8. Monitor treatment closely for needs/response to transfusion reactions. Identifies 8. . 7. 6.

changed due to *Restlessness consumed ¼ of the effects of * Poor appetite. 6. BUN.Monitor weight loss and effectiveness of 3. Advised to eat enhance intake. Rationale 1. After 5 days of nursing interventions. the patient nutrients many people necessary for experienced Objective Cues: the formation of some pain and *Weight: 53 kg normal RBC’s fatigue. Monitor laboratory results e. *demonstrate stable weight with normal 5. Encourage good oral care. Weight periodically as appropriate. the patient will: *have good appetite: consumed 2/4 of the food served. Hbg/Hct. increased appetite and be able to relieve body weakness and regain strength. goal was met as evidenced by good appetite: consumed 2/4 of the food served. the food served blood consumed ¼ of *decreased transfusion. *report absence Diminishes of nausea. bacterial growth increased minimizing appetite and be possibility of able to relieve infection body weakness and regain 6. Monitor caloric intake or insufficient quality of food consumption. verbalized by absorbing At this time. the food served tolerance for *Iron activity. To regain carbohydrates such as soft rice or bread. the “Wala akong than body body needs ganang kumain requirements extra calories at mabilis akong related to and protein for mapagod.Assessment Scientific Rationale Subjective Nutrition After Cues: Imbalanced less transfusion. and electrolytes. iron.g. goal was partially met as evidenced by *patient’s current weight is 55 kg. Evaluation After 8 hours of nursing interventions.” as deficiency of fast recovery. Collaborative: 5. Enhance laboratory appetite and oral values. strength and energy. folic acid. 2. Observe and record patient’s food intake. the patient will: *demonstrate stable weight with normal laboratory values. Replacements strength. After 5 days of nursing interventions. needed depend . supplement: weakness and Hemarate FA fatigue Diagnosis Planning After 8 hours of nursing interventions. *report absence of nausea. intake. The * c presence of as evidenced by: body's ability to body weakness * sudden weight use nutrients and fatigue loss may also be *nausea *poor appetite. May reduce fatigue and thus 4. 2. vitamin B12. Recommend nutritional small frequent meals interventions and/or between meal nourishment. 3. Nursing Interventions Independent: 1. food rich in 4.

.7. Vitamin B12. May be beneficial in some types of iron deficiency anemia. Administer medications as indicated.g. Vitamin and mineral supplements e. folic acid and vitamin C on type of anemia and/or presence of poor oral intake and identified deficiencies 7.

Rationale 1. bacterial colonization/ 3. Proper hand washing. Maintain strict aseptic technique 2. Evaluation After 8 hours of nursing intervention. After 4 days of nursing interventions. Monitor circulating risk for spread of temperature. Reduce risk of with procedures. Promote prevent interventions. which in turn can cause infection. It supports exhibit decrease 5. Encourage infection. adequate fluid pneumonia. Nursing Interventions Independent 1. *be able to verbalize understanding of health teachings provided to prevent spread of infection. Invasive procedures may contribute to the development of future infections. goal was met as evidenced by temperature at normal range. the patient will: *maintained normal range of temperature. volume and infection. Prevents cross contamination/ bacterial colonization. Planning After 8 hours of nursing intervention. goal was met as evidenced by *patient exhibited decrease risk for spread of infection. Any break in its continuity will allow microorganisms to enter the body. Note presence of tissue perfusion chills and and it aids in the tachypnea with elimination of or without fever. 2. . mobilizing After 4 days of secretions to nursing 4. microorganisms that may contribute to the occurrence of infection. the patient will: intake. *be able to verbalize understanding of health teachings provided to prevent spread of infection. Promotes ambulation/ ventilation of all coughing and lungs segments deep breathing and aids in exercise.Assessment Subjective Cues: ∅ Objective Cues: *Blood transfusion *c plain NSS 1L @ 900 cc level *T: 37 C *Platelet Count: 307 mm3 *c presence of body weakness and fatigue *pallor Diagnosis Risk for infection related to invasive procedure Scientific Rationale The skin is the first line of defense against infection. *be able to 4. frequent position changes/ 3.

5. To note for progress and evaluate for risk of infection .

Provide the patient will: information *verbalize about purpose. Encourage needs. 3. precautions and prognosis. Allays anxiety and may promote cooperation with therapeutics regimen. medications. goal was met as evidenced by patient verbalized understanding of disease process. Explain that complication of blood taken for blood laboratory transfusion. diagnostic procedures and potential complication of blood transfusion. procedures and potential 2. Recovery from anemia can be slow. information the patient will: about anemia * verbalize and explain that understanding of therapy depends the nature of the on the type and process. studies will not *verbalize worsen anemia. unspoken concern that can potentiate patient’s anxiety. schedule. understanding of dosage. Evaluation After 8 hours of nursing intervention. Rationale 1. prognosis. . * Verbalized understanding of therapeutic need After 5 days of nursing interventions. understanding of therapeutic 3. requiring lengthy treatment and prevention of secondary complications. Planning Nursing Interventions After 8 hours of Independent: nursing 1. severity of the diagnostic anemia.Assessment Subjective Cues: “Kapag natapos na ba ang pagsalin ng dugo. magiging maayos na ba ako. After 5 days of nursing interventions. Provides knowledge base from which patient can make informed choices. goal was met as evidenced by *patient verbalized understanding of the process. disease process. Provide interventions. Smoking decreases available oxygen and causes vasoconstriction 4. treatment. self care and discharge needs related to lack of exposure/recall information and unfamiliarity with information measures Scientific Rationale Presence of knowledge deficit is due to some unfamiliar information that causes confusion to the patient that needs to be discussed and clarified. 2. 4. This is often an. and adverse reaction potential to all prescribed complications. cessation of smoking.” as verbalized by the patient Objective Cues: *c presence of body weakness and fatigue *Restlessness *Inaccurate follow-through of instruction Diagnosis Knowledge deficit regarding condition. Information enhances cooperation with regimen.

Discuss increased susceptibility to infections. prognosis.g. Discuss the importance of taking oral iron preparation. . 7. 6. signs and symptoms requiring medical intervention e. fever. Iron supplements usually take 36mos.6. 7. Decreased leukocyte production potentiates risk of infection. and potential complications.

2. 5. 2. After 3 days of nursing 6. Employ a calm. Nursing Interventions Independent: 1. *absence of facial tension and improved attention span. 3. However. confident. the patient will be able to: *express decreased level of anxiety as evidenced by the patient appearing rested and relax. Enhances nurse/ patient relationship. 4. A feeling of interventions. To obtain baseline data. calm environment. self control & goal was met as success in evidenced by facilitating *patient breathing helps expressed . Environmental control of the changes may situation lessen the patient’s anxiety. 3. people who experience continues or recurring fears or episodes of intense fear can feel powerless to manage their symptoms and their lives can become severely restricted. deep breathing exercise and listening to music. Provide a quiet. *absence of facial tension and improved attention span. Monitor Vital Signs. Assess level of anxiety through verbal and nonverbal cues. caring. and non-judgmental approach. 6. Planning After 8 hours of nursing interventions.g. Encourage the use of breathing retraining & relaxation Rationale 1. Moderate or high level of anxiety can increase alertness and performance in particular situations. *verbalizes control of the situation After 3 days of nursing interventions. Identify areas of concern that might interfere with the normal progress of blood transfusion. 4. the patient will: *enumerate different methods of relaxation techniques.Assessment Subjective Cues: “Kinakabahan ako sa mga gagawin sakin.” as verbalized by the patient. *verbalized 5. Provides a healthy outlet of emotions and relieves anxiety. Evaluation After 8 hours of nursing interventions. goal was met as evidenced by *patient enumerated different methods of relaxation techniques e. Allow patient to express fears and feelings of anxiety appropriately. Objective Cues: *Exhibit poor eye contact *Facial tension observed *Short attention span Diagnosis Anxiety related to impending blood transfusion Scientific Rationale Anxiety is a normal experience.

Provides ongoing and timely support. Acknowledge normality of fear and provide opportunity for questions and answer honestly within client’s level of understanding. Adequate explanation helps reduce anxiety. 7. soothe fears. 1. Refer to support groups as needed. decreased level of anxiety as evidenced by the patient appearing rested and relax.techniques. and provides assurance. . Collaborative 1. reduce anxiety. 7.

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