NURSING CARE PLAN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Anemia, related to Long term:  Monitor  Decreased RBC indexes Long term:
The client states that decreased After 3 days of hemoglobin, are associated with After 3 days of nursing
she is feeling tired hemoglobin as nursing intervention hematocrit, decreased oxygen- intervention the client
and has shortness of evidenced by the client will be able RBC counts, carrying capacity of the has been able to achieve
breath exertional to achieve improved and blood. It is critical to improved condition
discomfort or condition from risk reticulocyte compare serial from risk factor.
dyspnea. factor. counts. laboratory values to
Objective:  Assist the evaluate progression or Short Term:
 Abnormal Short term: client in deterioration in the After 15 minutes of
labs (CBC = After 15 minutes of planning and client and to identify nursing intervention the
decreased nursing interventions prioritizing changes before they client verbalized
RBC and the client verbalizes activities of become potentially life- understanding of risk
HGB) understanding of risk daily living threatening. factor
 pale skin factor (ADL).  This will allow the client
 dizziness  Assist the to maximize his/her time
 dyspnea client in for accomplishing
 fatigue developing a important activities. Not
 headaches schedule for all self-care and hygiene
 irritability daily activity activities need to be
and rest. completed i the
Stress the morning. Likewise, not
importance of all housework needs to
frequent rest be completed in one
periods. day.
 Educate  Energy reserves may be
energy- depleted unless the
conservation client respects the
techniques. body’s need for
 Instruct the increased rest. A plan
client about that balances periods of
 medications activity with periods of
that may rest can help the client
stimulate RBC complete desired
production in activities without adding
the bone levels to fatigue.
marrow.  Clients and caregivers
 Provide may need to learn skills
supplemental for delegating task to
oxygen others, setting priorities,
therapy, as and clustering care to
needed. use available energy to
 Anticipate the complete desired
need for the activities. Organization
transfusion of and time management
packed RBCs. can help the client
conserve energy and
reduce fatigue.
 Recombinant human
erythropoietin, a
hematological growth
factor, increases
hemoglobin and
decreases the need for
RBC transfusions.
 Oxygen saturation
should be kept at 90% or
greater.
 Packed RBCs increase
oxygen-carrying capacity
of the blood.