NURSING EVALUATION

ASSESSMENT/ BACKGROUND
NURSING DIAGNOSIS GOALS AND OBJECTIVES INTERVENTIONS
CUES KNOWLEDGE
AND RATIONALE
SUBJECTIVE: Fatigue related to decreased Fatigue is one of the most
-39-year-old hemoglobin and hematocrit common symptoms of iron NOC: Endurance NIC: Energy Enhancement
-Post op from count secondary to anemia deficiency anemia. It occurs as a Partially Goal met:
cesarean section result of your body’s inability to The patient reports
- 36+2 weeks twin make sufficient amounts of Goal: The patient will report improved sense of energy
intrauterine hemoglobin, a protein that improve sense of energy and and exhibited improved
pregnancy carries oxygen to tissues exhibit improve symptoms of symptoms of fatigue as
throughout your body. fatigue as evidenced by increase evidenced by hgb of 13
OBJECTIVE: counts of hgb and hct. g/dl and hct of 38 counts.
-BP 100/80 In mild cases of iron deficiency

he
-HR 102 bpm anemia, the client is
-RR 24 bpm asymptomatic; in more severe -
-FHR B1=110; B2 cases, assessment reveals the Short-term Objectives:
After an hour of nursing
patient’s
90 general manifestations of anemia
-HGB 6g/dl including fatigue; headache; interventions, the patient:
-HCT 32 dyspnea; palpitations; pallor in ---

level of
-Ruptured the face, palm of the hand, nail
Membrane bed and mucous membranes of Establish rapport and  Verbalized 2
understandings of
- Emergency low the mouth and conjunctiva; therapeutic communication. causative factors for

anxiety
transverse angular stomatitis, glossitis, and (To gain the trust of the pt. fatigue:
cesarean section cheilitis; and brittle nails. involved.) - Lifestyle factors
(e.g., Lack of

will
(Medical-Surgical Nursing: Assess for possible reasons for sleep, , Not eating
Clinical Management for Positive fatigue. (Fatigue can be nutritious diet and
outcomes by Joyce M. Black and caused by physical, mental, or etc.)
Jane Hokanson Hawks, 8th edition)
significantl emotional stressors. Knowing
the exact reason and
contributing factors helps in
- Physical Health
Conditions
(Anemia)

y the planning of care.) 

Assess the nutritional status.

drop, (Adequate calorie intake from

good sources can affect
accompani
someone’s level of fatigue.
Inadequate food intake can
lead to deficiencies that can

ed by cause fatigue. Deficient

vitamins and iron can lead to
feeling tired.)

her Evaluate the patient’s sleeping

pattern, such as Difficulty

verbalizati falling asleep and Difficulty

staying asleep. (Inadequate

on of
amounts of sleep can lead to
fatigue.)
Consider the chief complaint
such and review the past medical
history. (The patient’s current

improvem condition may contribute to

feeling tired. Comorbidities
and other illnesses could also

ents and play a role in the patient’s

symptoms of lack of energy.)

demonstrat ---
Provide a quiet environment.  Identified 3 ways to

ion of (Additional stressors can

intensify the pt. perception
and tolerance of anxiety)
relieve fatigue.
- Rule out health

effective
problems
Allow the patient to express - Eat a balanced
feelings about fatigue. (The diet or Prioritize

relaxation patient’s point of view can iron-rich foods

give valuable insight into his and Stay Hydrated
or her awareness and - Get enough sleep
motivation to improve fatigue
techniques
symptoms.)
a Assist the patient in
nd demonstration of effective developing fatigue-reducing
relaxation techniques skills. (Using fatigue-
reduction strategies enhances
patient's sense of personal
mastery and confidence.)

Short-term Objectives: Collaborate with the attending

After an hour of nursing physician about optimizing
interventions, the patient will be medications. (Certain
able to: medications such as sleep
medications, sedatives, pain
 Verbalize 3 understandings medications, and others can
of causative factors for contribute to fatigue.
fatigue: Adjustments in frequency and
- Lifestyle factors (e.g.,. dosing could improve
Lack of sleep, Physical symptoms of fatigue.)
exertion, Not eating
nutritious diet and etc.)
- Physical Health Long-term Objectives:
Conditions (e.g.,. After 3 days of nursing
Anemia, Cancer, interventions, the patient:
Diabetes, Chronic
fatigue syndrome and
etc.) ---
- Mental health issues
(e.g.,. anxiety, depression Monitor patient’s vital signs.  Exhibited normal vital
and seasonal affective (To detect any changes or signs as evidenced by
disorder.) deterioration on vital signs.) no hypotension; no
tachycardia; no
Teach family members and hypoxemia.
caregivers signs of
overexertion. (Increased heart
rate, Increased blood pressure,
increased respiratory rate,
 increased oxygen demand)
(Regular checks of vital signs
and an overall observation of
the patient’s general
appearance will reveal their
activity level.)   
---
Observe physiological
reaction to activities such as  Reported increased
any alterations in BP, energy.
respiratory rate, or heart rate.
(Tolerance varies
significantly, depending on the
phase of the disease
progression, nutrition
condition, fluid balance, and
quantity or sort of
opportunistic diseases that
patient has been subjected to.
 Identify 4 ways to relieve ---
fatigue.  Displayed an
- Rule out health problems Review the patient’s lab acceptable range of
- Eat a balanced diet or values. (Hemoglobin, laboratory values of
Prioritize iron-rich foods hematocrit, Blood glucose and Hgb and Hct.
and Stay Hydrated etc.) (Anemia, low blood
- Get enough sleep sugar, and other physiological
- Manage stress (e.g., deep changes due to underlying
breathing techniques,
disease can cause fatigue.)
meditation)
Long-term Objectives:
After 3 days of nursing
interventions, the patient will be
able to:

 Exhibit normal vital signs.

 Reports increased energy.

 Display an acceptable range

of laboratory values of Hgb
and Hct.