NAME: OLUSEGUN-OBIWUSI, OLUFUNKE DATE: _____________

BSN 3 Sec 1 Grp X

ASSESSMENT EXPLANATION OF THE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

PROBLEM

Subjective: The patient was STO: Dx: STO:

hospitalized to receive
"I feel weak and I chemotherapy Within 30 minutes-1  Identified presence of  To assess the specific (Goal Met)
easily get tired. I treatment for hour of effective physiological condition (s) cause of fatigue this is
think I don't have nursing interventions, e.g. anemia. mostly due to tissue Within 30
endometrial adenoma minutes-1 hour
energy". carcinoma. the patient will be able hypoxia from
to: normocytic anemia. of effective
Objective: Chemotherapeutic nursing
agents are notorious a) identify basis of  Assessed ability to perform  Fatigue can limit the interventions,
 With pallor and for suppressing the activities of daily living.
fatigue and individual patient's ability to the patient
pale bone marrow, this areas of control. participate in self-care. identified the
conjunctiva results in the patient basis of fatigue,
 Measured physiological
 Needs having low b) verbalize  To determine degree of how she can
response to activity .e.g.
assistance with hemoglobin and understanding of the changes in respiratory rate. fatigue and impact on control it,
activities of hematocrit levels use of energy life. verbalized
daily living respectively, leading conservation understanding
 Exertional to her having anemia. principles.  Reviewed laboratory  Decreased RBC indexes
of the use of
discomfort Anemia is the most results of blood profile are associated with
c) participate in decreased oxygen- energy
(RR=22 cpm) common hematologic particularly red blood cells
recommended carrying capacity of the conservation
 Low disorder in which the indexes.
treatment program. principles and
hemoglobin hemoglobin level is blood.
Tx: took the
level - 88g/L lower than normal, prescribed
 Low reflecting the  Accepted reality of  Report of fatigue is medications
hematocrit presence of a patient’s reports of fatigue subjective and only the accordingly.
level - 0.26L/L decrease in the and effect on patient’s patient can explain it.
number or quality of life.
derangement in the
 function of red blood LTO:  Assisted with activities of  To help conserve LTO:
cells within the daily living and promoted energy and assist in
Nursing Diagnosis: circulation. As a result, Within 24-48 hours of comfort and rest. coping with fatigue. (Goal Met)
the amount of oxygen effective nursing
FATIGUE related to interventions, the  Promoted safety by  Because of inability to Within 24-48
decreased delivered to body hours of
tissues is also lessened, patient will: constant monitoring, maintain usual level of
hemoglobin level keeping bed in low physical activities, safety effective nursing
and diminished leading to a feeling of a) report improved interventions,
reduced level of position and travel ways may be compromised.
oxygen-carrying sense of energy clear of furniture. the patient
capacity of the energy, increased reported
blood secondary to respiratory rate with b) perform ADLs and  Ensured the patient took  To promote absorption improved sense
anemia as little work and inability participate in desired the prescribed medication of iron as milk decreases of energy was
manifested by a to perform activities of activities at level of of FeSO4+Folic acid with absorption. seeing walking
decreased sense of daily living; collectively ability. water or orange juice and unassisted to
energy and known as, FATIGUE, not milk. the comfort
which is defined as an
capacity for  Packed red blood cells room and was
physical work. overwhelming  Administered and able to perform
increase oxygen-
sustained sense of regulated the packed red activities of
carrying capacity of the
exhaustion and blood cells flow rate as daily living by
blood thereby reducing
decreased capacity ordered. herself.
fatigue.
for physical and
mental work at usual Edx:
level (NANDA).  All these measures can
 Educated on energy-
conservation techniques help the patient
such as delegating tasks to conserve energy and
SOURCE/S: others, having frequent reduce fatigue.
rest periods and doing
McCance, K.L. & deep breathing exercise
Huether, S.E. (2017). when exhausted.
Understanding
Pathophysiology: The  Encouraged to increase  To stimulate red blood
Biologic Basis for the consumption of foods cells production in the
 Disease in Adults and high in dietary iron such as bone marrow thereby
Children (6th ed.). St. malunggay, spinach and improving the
Louis: Elsevier/Mosby. liver. And also the intake of hemoglobin level and
foods high in folic acid and facilitating optimum
Potter, P.A., Perry, vitamin B12 such as green recovery from anemia.
A.G., Stockert, P.A., & leafy vegetables and dairy
Hall, A.M. (2018). products.
Essentials for Nursing
Practice (9th ed.). St.  Instructed patient in ways  To prevent accidents
Louis: Elsevier. to monitor responses to and promote wellness.
activity and significant
Potter, P.A., Perry, signs/symptoms that may
A.G., Stockert, P.A., & indicate the need to alter
Hall, A.M. (2017). activity level.
Fundamentals of
Nursing (9th ed.). St.
Louis: Elsevier/Mosby.  Advised to report promptly  To ensure timely
any untoward feelings and intervention and
www.nurseslab.com concerns. prevent complications.

ASSESSMENT:
1. Focus on your Nursing Diagnosis (Subjective and Objective cues should ALL be align with your problem)
2. Subjective data (preferably verbalization from the patient and must be in an open and close quotation otherwise if it is coming from the mother
or any significant other, it must be categorize as subjective data from a secondary source or an objective data [if it can be perceived by the
senses, verified by another person observing the same patient, and tested against accepted standards or norms] from a secondary source).
3. Objective data (start with the most obvious observation that is related to your nursing diagnosis to the less obvious, followed by abnormal vital
signs that are related to your problem and any laboratory results that are relevant to your problem)
4. For Nursing Diagnosis, use the 3-Part Statement: PES Format (Problem + Etiology + Signs and Symptoms) Three parts are joined together by
“related to” or “associated with” and “as manifested by” or “as evidenced by”
EXPLANATION OF THE PROBLEM:
1. Should be in paragraph form, it’s just like doing your pathophysiology but explaining in detail how the problem arise in relation to your objective
data and other signs and symptoms manifested by the patient that are related to your problem.
 2. DO NOT FORGET to indicate your source as a basis in coming up with your explanation of the problem.
OBJECTIVES:
1. Must follow the concept of SMART (Specific, Measurable, Attainable, Realistic and Time bound).
2. STO (Short Term Goal). In theory it covers your acute care (till 6 months). But for our requirement we measure our STO within the shift (0 – 8 hours).
A better parameter would be using ranges of time depending on the planned activities.
3. LTO (Long Term Goal). In theory it covers your chronic care (6 months and above). But for our requirement we measure our LTO within the first day
to the third day or one rotation (24 – 72 hours). A better parameter would be using ranges of time depending on the planned activities.
NURSING INTERVENTION:
1. Dx (diagnostics) should be based on your SUBJECTIVE and OBJECTIVE DATA.
2. Tx (therapeutics) should be arrange as ICDS (Independent nursing function, Collaborative [other health-care professional aside from the
physician], Dependent nursing function [physician/doctor], Supportive [Significant others, clergy/priest, and non-health care professional]
3. Edx (educative) should be based on the most needed by the patient that is relevant to the nursing diagnosis. (you can also base it on your STO
and LTO if there are educative goal)
RATIONALE:
1. It must be aligned with your nursing intervention and relevant to the case of you patient.
2. For the administration of medication, your rationale should be the indication of the drug in relation with the patient’s case.
EVALUATION/ EXPECTED OUTCOMES:
1. Evaluation for ACTUAL PROBLEM and your NURSING INTERVENTION should be past tense.
2. EXPECTED OUTCOME for POTENTIAL PROBLEM and your NURSING INTERVENTION should be future tense.
3. Should evaluate (GOAL MET, GOAL NOT MET or GOAL PARTIALLY MET) accurately and should be supported by results from your STO and LTO.
4. For expected outcomes (GOAL MET IF, GOAL NOT MET IF or GOAL PARTIALLY MET IF), and give parameters for the IF.
5. Should discuss or make recommendation/s for goal not met and partially met.

Always remember that NURSING PROCESS is SYSTEMATIC, PATIENT-CENTERED, GOAL-ORIENTED AND DYNAMIC.