Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Independent:
Ineffective After 15 1. Position the 1. This promotes Goal met after
“I’m Having breathing minutes of Patient into semi- maximum lung 15 minutes of
shortness of Pattern related proper fowler position as expansion and proper nursing
breath aggravated to protrusion nursing tolerated. assists in interventions
with exertion and of the stomach interventions, breathing. the patient
after meals” as from hiatus the patient shortness of
verbalized by the into chest shortness of 2. It Improves breath is now
patient. cavity as breath will be 2. Instruct patient breathing pattern alleviated as
evidenced by alleviated as pursed-lip by moving old evidenced by
Objective: shortness of evidenced by breathing air out of the relaxed
(+) Pallor breath relaxed technique. lungs and breathing.
observed at aggravated breathing allowing for new
conjunctiva. with exertion air to enter.
& after the
Tiredness ingestion of 3. Supine
Food. position after
meals can
3. Have the patient increase
sit upright position regurgitation of
1-2 hrs. after meals acid and full
do not lie down stomach increase
after eating. the pressure on
the diaphragm
that contributes
to patient
shortness of
breath.

4. These
clothing restrict
the stomach and
chest that
4. Tell patient to contributes to
loosen any tight shortness of
clothing and breath.
encourage patient
to avoid using or 5. It is important
wearing tight to act when there
clothing. is an alteration
in the VS
especially in the
5. Monitor patient pattern of
Vital signs breathing to
including 02 detect early
saturation. signs of
respiratory
compromise.
 Dependent:

6. Administer 6. For
oxygen as ordered management of
by the physician. respiratory
distress and
cyanosis.

Collaborative:

7. Consult/ refer the 7. Very large

patient to surgeon hernia may
for possible require surgery
surgery. especially when
the hernia is
already affecting
some major
organs of
thoracic cavity.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective data: Long term: Independent: Independent:

Laboratory Fatigue related After 3 hours 1. Get & 1. To have Goal met
Evaluation: to decreased of nursing Monitor patient baseline data of after 3 hours
Hgb:10.9g/dL(Low) hemoglobin intervention the vital signs. the patient VS. of nursing
Iron 18ug/dL and diminished patient will intervention
MCV:72.3 fL(Low) oxygen- able to perform 2. Restrict 2. Vivid lightning, the patient
Shortness of breath carrying ADLs and environmental noise, visitors, will able to
Increasing fatigue capacity of the participate in stimuli, numerous perform
Pallor was observed blood as desired especially during distractions, and ADLs and
at conjunctiva evidenced by activities at planned times litter in the patients participate in
(+) Fecal occult inability to level of ability. for rest and physical desired
blood test. maintain usual sleep. surroundings can activities at
level of limit relaxation level of
physical disturb rest can ability.
activity contribute to
fatigue.

3. Encourage the 3. To extent active

use of assistive time/conserve
devices (e.g. energy for other
wheel chair & tasks..
wheel walker)
4. It is critical to
4. Monitor Hgb, compare serial
Hct, RBS counts, laboratory values
reticulocyte to evaluate
counts. progression or
 deterioration in the
client and to
identify changes
before they
become potentially
life-threatening.

5. Advise patient 5. Iron is best

to take iron absorbed in empty
supplements an stomach for
hour before maximum
meals or 2 hours absorption.
after meal.

6. Inform patient 6. Black or dark

that iron changes stools are common
stool to dark side effect that may
green or black. be the harmless
result of
unabsorbed iron.

Dependent: Dependent:
7. Administer 7. To treat or
parenteral iron prevent low blood
as prescribed by levels of iron. Iron
the physician. is an important
(using z-tract mineral that the
injection). body needs to
produce red blood
cells and keep you
in good health.
Lack of iron cause
fatigue.

Collaborative: Collaborative:
8. Teach energy 8. Patients and
conservation caregivers may
methods need to learn skills
collaborate with for delegating task
occupational to others, setting
therapist as priorities and
needed. clustering care to
use available
energy to complete
desired activities.