Nursing Care Plan

CUES NURSING GOALS ADND NURSING INTERVENTION IMPLEMENTATION EVALUATION

DIAGNOSIS DESIRED
OUTCOME
Objective Cues: Fatigue related The patient’s Hgb Check oximetry; inform physician 02 saturation 92% Monitor hemoglobin,
 Inability to maintain to anemia and and Hct level are or less. hematocrit, RBC counts,
usual level of diminished normal. Rationale: This will determine the need for and reticulocyte counts.
supplementary oxygen if 02 saturation 92% or less.
physical activity oxygen-carrying Patient will Check oximetry; inform
such as self-care capacity of the verbalize use of Assess the specific cause of fatigue.
physician 02 saturation
activity as evidence blood. energy conservation Rationale: The specific cause of fatigue is due to 92% or less.
by difficulty in principles. tissue hypoxia from normocytic anemia; Other related Give Health Teaching on
eating independently Patient will medical problems can also compromise activity the medication given,
and drinking water. verbalize reduction tolerance. contraindication,
 Drowsy and restless of fatigue, as indication and do’s and
facial expression evidenced by Monitor hemoglobin, hematocrit, RBC counts, and don’ts when given the
reports of increased reticulocyte counts. medication.
 Pale lips, lower Rationale: Decreased RBC indexes are associated
extremities and as energy and ability Instruct the client about
with decreased oxygen-carrying capacity of the blood.
well as her lips and to perform desired It is critical to compare serial laboratory values to medications that may
palms. activities. evaluate progression or deterioration in the client and stimulate RBC production
 Report of fatigue and Patient will regain to identify changes before they become potentially in the bone marrow and
lack of energy as energy as evidence life-threatening. Elemental iron
evidenced by by independency on Educate energy-conservation techniques. supplement.
performing self- Rationale: Clients and caregivers may need to learn Give Health Teaching on
difficulty in turning
care without skills for delegating task to others, setting priorities, energy-conservation
to sides. and clustering care to use available energy to complete
 Low-Hematocrit assistance. techniques.
desired activities. Organization and time management
(34.10) and can help the client conserve energy and reduce  Set up proper
Hemoglobin (10.8) fatigue. working
as evidenced by Instruct the client about medications that may conditions
latest CBC count stimulate RBC production in the bone marrow and  Avoid
(taken on 12-13- Elemental iron supplement. unnecessary
Rationale: Recombinant human erythropoietin, a motions
2019 7:15 am)
hematological growth factor, increases hemoglobin  Avoid rushing
and decreases the need for RBC transfusions.
Vital Signs: Provide supplemental oxygen therapy, as needed.  Never hold your
T: 36.5˚c Rationale: Oxygen saturation should be kept at 90% breath during
BP 140/100 mmHg or greater. activity
RR: 24 bpm Anticipate the need for the transfusion of packed  Inhale when
PR: 70 bpm RBCs. lifting your
 Rationale: Packed RBCs increase oxygen-carrying arms up or
Subjective Cues: capacity of the blood. when extending
. the trunk
The patient expresses her  Exhale when
need of increased rest bringing arms
requirements as verbalize down & when
“human daon (surgery) bending the
kinahanglan man mag trunk
pahuway nako. ”  Exhale also
(After surgery, I necessarily during any
need to rest…”) physical
exertion (don’t
hold your
breath)

Hygienic measures
(showering rather than
bathe in a tub).

Avoid wearing tight-

fitting or constricting
undergarments made of
non-breathing materials.

CUES NURSING GOALS ADND NURSING INTERVENTION IMPLEMENTATION EVALUATION

DIAGNOSIS DESIRED
OUTCOME
Objective cues: Risk For Client will have a Assess for local or systemic signs of Assess for local or
 A surgical incision Infection reduced risk of infection, such as fever, chills, swelling, systemic signs of
is present in the related to infection as pain, and body malaise. infection, such as fever,
abdomen region. anemia evidenced by an Rationale: Opportunistic infections can chills, swelling, pain,
 The patient’s absence of fever, easily develop, especially in and body malaise.
Neutrophils (84%) normal white immunocompromised clients. Monitor WBC count.
and White Blood blood cell count, Monitor WBC count. Instruct the client to
 Cells (12.88) are and Rationale: A low white blood cell count report signs and
elevated. implementation of (leukopenia) is a decrease in disease- symptoms of infection
 The patient’s preventive fighting cells (leukocytes) in your blood. In immediately.
family is not measures such as general, for adults a count lower than 4,000 Instruct the client to
practicing a proper proper hand white blood cells per microliter of blood is avoid contact with
hand washing washing. considered a low white blood cell count. people with existing
technique. Client will have Instruct the client to report signs and infections.
vital signs within symptoms of infection immediately. Instruct the client to
Vital Signs: the normal limit. Rationale: A simple fever is significant avoid eating raw fruits
The patient’s enough not to pay attention to. A need for and vegetables and
T: 36.5˚c white blood cells antibiotic therapy may be indicated. uncooked meat.
BP 140/100 mmHg and neutrophil Instruct the client to avoid contact with Stress the importance
RR: 24 bpm level are normal. people with existing infections. of daily hygiene,
PR: 70 bpm Rationale: These can be a source of mouth care, wound
infection for the immunocompromised dressing and perineal
Subjective cues: client. Children, 12 years of age or younger care.
are at risk because they can be carriers of Teach the client and
infection, especially upper respiratory visitors the proper hand
infection. washing.
Instruct the client to avoid eating raw fruits
and vegetables and uncooked meat.
Rationale: These food items can harbor
bacteria. A low bacterial diet protects the
client from exposure to pathogens.
Stress the importance of daily hygiene,
mouth care, wound dressing, and perineal
care.
Rationale: These preventive measures help
avoid skin breakdown and lessen the risk of
infection.
Teach the client and visitors the proper
hand washing.
Rationale: Practicing hand hygiene is an
effective way to prevent infections.
Washing hands can prevent the spread of
germs, including those that are resistant to
antibiotics.