ASSESSMENT Subjective: Nahihirapan siyang huminga tapos nanlalamig yung mga kamay niya Objective: Capillary Refill=4 secs

RR=35 cpm PR=126 bpm Restlessness Nasal flaring Cyanosis RBC Count : 2.40x106/ul. Hemoglobin: 7.8g/dl Cold, clammy skin

NURSING DIAGNOSIS Ineffective tissue perfusion related to decreased hemoglobin concentration

PLANNING Short Term: Within 30 minutes of nursing interventions the client will be able to : y y express relief from chest pain express a decrease in the respiratory rate from 35-25 cpm

INTERVENTION Independent : 1. Administered oxygen at 2-3 LPM as needed

RATIONALE

EVALUATION GOALS MET

This saturates circulating hemoglobin and increases the effectiveness of blood that is reaching the ischemic tissues This promotes optimal lung ventilation and perfusion

2. Instructed to assume an high fowler s position

Long Term: After 3 days of nursing interventions the client will be able to: y Increased perfusion as manifested by: o Capillary refill <3 secs o RR= 16-20 cpm o PR=80-100 bpm o Acyanosis o RBC (4.6-6.2 x106/ul) and hemoglobin (1018g/dl) count

3. Provided a quiet and calm environment 4. Encouraged to perform passive ROM exercises on the extremities every 2-4 hours 5. Instructed to avoid measures that may increase cardiac workload such as straining, coughing, neck or hip flexion and lying supine

Conserves energy and lowers oxygen demand of tissues Prevents venous stasis and helps maintain muscle tone of extremities

These activities may increase ICP and further reduce blood flow

Iron is needed for the

within normal parameters

6. Encouraged intake of iron rich foods such as green leafy vegetables

production of hemoglobin which in turn supplies oxygen to tissues

Dependent: y 1. Administered iron supplements as indicated Provides supplemental iron that can help improve hemoglobin level

2. Administered Vitamin C as indicated

Enhances absorption of iron in the gastrointestinal tract