XIV.

PROBLEM LIST

A) Actual Problems

Problem No. Nursing Diagnoses Date Identified

1 Deficient Fluid Volume February 26, 2020
2 Activity Intolerance February 26, 2020
3 Fatigue February 26, 2020

B) Potential Problems

Problem No. Nursing Diagnoses Date Identified

1 Anxiety February 28, 2020
2 Risk for Spiritual Distress February 26, 2020
XV. NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Actual and Abnormal Deficient fluid volume After 2 days of . INDEPENDENT
findings: related to blood loss as nursing intervention, After 3 days of
evidenced by vaginal client will be able to:  Monitor active fluid - Maintain accurate nursing intervention,
Subjective data: bleeding for almost a loss from bleeding input and output. client was able to:
Patient says month, decreased a. Experience
“Ang daming hemoglobin and adequate fluid  Monitor  Febrile states
lumabas sa akin hematocrit result. volume and temperature decrease body a. Goal met. Patient
na dugo.” electrolyte balance. fluids through experiences
perspiration and adequate fluid
Objective data: increased volume and
decreased respiration. electrolyte balance
hemoglobin and as evidenced by
hematocrit count  Encourage - Oral fluid urine output greater
profused patient to drink replacement is than 30 ml/hr,
menstruation prescribed fluid indicated for mild normal vital signs
amounts. fluid deficit. and normal skin
Will be able to identify turgor.
some management to  Monitor serum - Elevated
maintain health electrolytes and hemoglobin and
urine osmolality elevated blood urea b. Goal met. The
and report nitrogen (BUN) patient was able to
abnormal suggest fluid deficit. understand the
values. Urine-specific importance of taking
gravity is likewise supplements
increased. especially iron and
COLLABORATIVE eating nutritious
foods
Assist the physician - This allows more
with insertion of a effective fluid
central venous line administration and
and arterial line as monitoring.
indicated.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Activity Intolerance . Short Term: Independent: Short Term:

“Nahihirapan akong related to imbalance - After 3-4 hours of Assess Signs of activity The patient shall
gumalaw” as stated by between oxygen supply nursing intervention, manifestations of intolerance and gain her energy.
the patient and demand as the patient will her gain activity intolerance. decreased tissue
evidenced by energy Tell the patient to oxygenation include Long Term:
generalized weakness rate perceived dyspnea on The patient shall
Long Term: exertion on a 0-10 exertion, increased her
Objective: - After 1 week of scale. headaches, hemoglobin and
Pale looking nursing intervention, dizziness, hematocrit back to
Hgb : 4.8 g/dl (Normal the patient will increase palpitations, and its normal value
Range: 11.0 - 15.0 g/dl) her hemoglobin and verbalization of
Hct : 18.7% (Normal hematocrit back to its increased exertion
Range: 33.0 - 46.0%) normal value level (rated
perceived exertion
or RPE is more than
3). Patient should
end or lessen the
activity until signs of
increased exertion
are no longer
present.

Allow time for the Lessening any

patient to have interruptions allows
undisturbed rest. the patient to rest
and benefit from
sleep until anemia
is resolved.
Dependent:
Give blood This method will
components increase the
(commonly packed number of RBCs
RBCs) via circulating in the
intravenous blood, which
catheter as eventually increase
prescribed. the blood’s oxygen-
carrying capacity.

Collaborative:
Observe and report These measures
for any signs of lessen the risk of
transfusion reaction. transporting the
Confirm type and wrong type of blood
crossmatching to the patient.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Fatigue related by Short Term: Independent:

Subjective: decreased hemoglobin Assess the specific The specific cause of Short Term:
“nanlalambot ako” as and diminished - After 3-4 hours of cause of fatigue. fatigue is due to tissue
stated by the patient. oxygen-carrying nursing intervention, hypoxia from The patient shall gain
capacity of the blood. the patient will her gain normocytic anemia; her energy.
energy Other related medical
problems can also
Objective: compromise activity
Long Term:
Pale looking tolerance.
Long Term: The patient shall
Hgb : 4.8 g/dl (Normal increased her
Range: 11.0 - 15.0 g/dl) - After 1 week of Assess the client’s Fatigue can limit the
hemoglobin and
Hct : 18.7% (Normal nursing intervention, ability to perform client’s ability to
hematocrit back to its
Range: 33.0 - 46.0%) the patient will increase activities of daily living participate in self-care
normal value
her hemoglobin and (ADLs), and the and perform his or her
hematocrit back to its demands of daily living, role responsibilities in
normal value family and society,
such as working
outside the home.

Dependent: Packed RBCs increase

Anticipate the need for oxygen-carrying
the transfusion of capacity of the blood.
packed RBCs.

Collaborative:
Monitor hemoglobin, Decreased RBC
hematocrit, RBC indexes are associated
counts, and reticulocyte with decreased
counts. oxygen-carrying
capacity of the blood. It
is critical to compare
serial laboratory values
to evaluate progression
or deterioration in the
client and to identify
changes before they
become potentially life-
threatening.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Anxiety related to After continuous -encourage this aids comfort by After continuous
Subjective change in Health status nursing intervention, verbalization of improving the patients nursing intervention,
as evidence by the client will be able concerns attitude toward the the client was able to:
“hindi ako mapalagay irritability. to: situation.
kasi baka hindi ako -assist patient in -verbalized appropriate
gumaling agad.”As -Verbalize appropriate expressing feelings by range of feelings.
verbalized by the range of feelin active listening
patient
-provide accurate and
concrete information
Objective about what is being
done -relieves discomfort
>Irritability >poor eye and pain
contact >Expressed -provide a calm and
concerns due to peaceful environment
change in life events
>dry mouth -encourage relaxation
techniques

-encourage to project a
positive and realistic
attitude
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Spiritual distress After 3 hours of nursing Be open to the Encourages expression Outcome met, the
“Bakit ako ginanito ng related to feeling of intervention the patient Patient’s feelings of inner fears and patient is Hoping
Panginoon?,” as alienation from God as connects with others to about illness and concerns and teaches against hope with
evidence by share thoughts, death. the client the value of
stated by the patient. “God’s mercy and will
questioning “ bakit ako feelings, and beliefs. confronting issues.
ginanito ng help her bear her
Objective: Panginoon?” Observe and listen The nature of spiritual suffering.
Crying empathetically to her care may directly
Loss of appetite communication. affect the speed and
quality of recovery
and/or redefining
hope and finding
meaning in death.