Nursing Care Plan

Assessment Nursing Pathophysiologic Desired Nursing Rationale Evaluation

Diagnosis Basis/Rationale Outcome Interventions

Actual Cues Activity Inherited blood After 8 hours of 1. Note patient reports of 1. To identify causative/ After 8 hours of nursing
Subjective: intolerance r/t disorder nursing intervention, weakness, fatigue, pain precipitating factors intervention, patient will
“ Ga pang luya ko imbalance patient will be able and difficulty be able to:
kag daw waay gid between oxygen Reduction of the to: accomplishing tasks
ko gana mag giho supply and production of 2. Assess cardiopulmonary 2. To identify causative/ GOAL :
kay na budlayan gid demand functional 1. Identify negative response to physical precipitating factors 1. Response to
ko.” as verbalized hemoglobin factors affecting activity, including vital interventions/teaching
by the patient. Definition: activity tolerance signs before, during and and actions performed
Insufficient Reduced levels of and eliminate or after activity. Note
psychological or B-globin chains reduce their progression/accelerating GOAL :
Objective: psychological effects when degree of fatigue. 2. Implemented changes
Vital Signs energy to endure Absence of B- possible 3. Ascertain ability to stand 3. To prevent injury and to plan of care based
T: 37 °C or complete globin chains 2. Use identified and move about and complications on assessment /
PR: 81 bpm required or techniques to degree of assistance reassessment findings
RR: 21 bpm desired daily Excess free a enhance activity necessary/use of
BP: 90/50 mmhg activities chains tolerance equipment GOAL :
3. Participate 4. Assess emotional/ 4. Feelings of frustration / 3. Teaching plan and
• Pallor Membrane willingly in psychological factors powerlessness may impede response/
• Limited range of damage to necessary/ affecting the current attainment of goals understanding of
motion Peripheral RBC desired activities situation teaching plan
• Leg cramps 4. Report
• Dizziness Hemolysis measurable 5. Provide/monitor 5. Assist patient to deal with GOAL
• D i f f i c u l t y Reference: increase in response of supplemental contributing factors and 4. Attainment/progress
concentrating Nurse’s Pocket Anemia activity tolerance oxygen and medications manage activities within toward desired
Guide 8th and changes in treatment individual limits outcome(s)
Edition Imbalance regimen.
between oxygen
supply and
demand
 5. Demonstrate a 6. Monitor vital/cognitive 6. To assess the client for
Weakness decrease in signs, watching for changes any condition that may occur
physiological signs in blood pressure, heart and during the course of her
Activity of intolerance respiratory rate; note skin illness.
intolerance pallor and/or cyanosis and
presence of confusion

7. Assist patient to learn 7. To promote wellness

and demonstrate
appropriate safety measures
to prevent injuries

8. Provide information 8. To promote wellness

about the effect of lifestyle
and overall health factors non
activity tolerance (e.g.,
nutrition, adequate fluid
intake, mental health status)

9. Encourage patient to 9. To reduce anxiety

maintain positive attitude

10. Encourage participation 10. Enhances self-concept

in recreational/social and sense of independence
activities and hobbies
Reference: Nurse’s appropriate for situation.
Pocket Guide 8th
Edition Reference: Nurse’s Pocket
Guide 8th Edition
 Assessment Nursing Pathophysiologic Desired Nursing Rationale Evaluation
Diagnosis Basis/Rationale Outcome Interventions

Actual Cues Ineffective tissue Inherited blood After 8 hours of 1. Monitor blood 1. To know the baseline of After 8 hours of nursing
Subjective: perfusion r/t reduced disorder nursing intervention, pressure blood pressure intervention, patient will
“Kinanlan ko cellular components patient will be able be able to:
tugongan dugo kay that are essential to Reduction of the to: 2. To reduce edema that
kulang ko sa dugo.” deliver pure oxygen production of 2. Instruct to have may activate renin GOAL :
as verbalized by the to the cell AEB as functional hemoglobin 1. Demonstrate enough rest on angiotensin-aldosterone 1. Attainment / progress
patient. evidenced by behaviors / semi-fowler’s system toward desired
hemoglobin count of Reduced levels of B- lifestyle changes position outcome(s)
Objective: 14 g/l globin chains to improve 3. Sodium tends to be
Vital Signs circulation (e.g. excreted at a faster rate GOAL :
T: 37 °C Definition: Decrease Absence of B-globin relaxation 3. Instruct to eat 2. Response to
PR: 81 bpm in oxygen resulting chains techniques, ow fat and salt interventions/
RR: 21 bpm in the failure to dietary program) diet teaching, actions
BP: 90/50 mmhg nourish the tissues at Excess free a chains 2. Demonstrate performed
the capillary level increased
• Low hemoglobin (Tissue perfusion Membrane damage to perfusion as
level: 14g/L problems can exist peripheral RBC individually
• Pale conjunctiva without decreased appropriate
and nail beds cardiac output; Hemolysis
• Weakness however, there may
• C o l d c l a m m y be a relationship Reduced cellular
skin between cardiac components that are
• Cyanotic lips output and tissue essential to deliver
• Decreased skin perfusion) pure oxygen to the cell
turgor > 4
seconds Ineffective tissue Reference:
• D e c r e a s e d Reference: Nurse’s perfusion Nurse’s Pocket
capillary refill > Pocket Guide 8th Guide 8th
4 seconds Edition Edition
 Assessment Nursing Pathophysiologic Desired Nursing Rationale Evaluation
Diagnosis Basis/Rationale Outcome Interventions

Actual Cues High risk for Blood transfusion After 8 hours of 1. Note risk factors for 1. To assess etiology After 8 hours of nursing
infection r/t nursing intervention, occurrence of infection precipitating contributory intervention, patient will
No subjective and inadequate patient will be able factors be able to:
objective cues secondary to:
because a risk defenses and 2. Observe for localized 2. To identify infectious GOAL :
diagnosis is not immunosuppress 1. Verbalize signs of infection at process and promote 1. Response to
evidenced by signs ion understanding of insertion sites of invasive timely intervention interventions/teaching
and symptoms, as individual lines and actions performed
the problem has not Definition: At causative/risk 3. Assess and document 3. To note for complications
occurred and increased risk factor(s) skin conditions around present GOAL :
n u r s i n g for being 2. Identify insertions of IV 2. Attainment/progress
interventions are invaded by interventions to toward desired
directed at pathogenic prevent/reduce 4. Note signs and 4. To identify causative/ outcome(s)
prevention organisms. risk of infection symptoms of sepsis: precipitating factors 3. Modifications to plan
3. Demonstrate fever chills, diaphoresis, of care
techniques, altered level of
lifestyle changes consciousness, positive
to promote safe blood cultures
environment 5. Stress proper hand 5. First-line defense against
4. Achieve timely washing techniques by nosocomial infections
wound healing; all caregivers between
be free of therapies/patients.
purulent
drainage or
erythema; be
afebrile
Reference:
Nurse’s Pocket Reference: Nurse’s
Guide 8th Pocket Guide 8th Reference: Nurse’s Pocket
Edition2 Edition Guide 8th Edition