ColleGE of NURSING

NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
(Subjective and DIAGNOSIS
Objective)
Subjective: Ineffective tissue Blood is a connective tissue Within our care, the Independent: Within our care,
“I started perfusion related comprised of a liquid extracellular client will be able 1. Establish  To gain trust client had
feeling a little bit to decreased matrix termed as blood plasma to: rapport and client regained full
dizzy and then hemoglobin which dissolves and suspends cooperation consciousness and
after that I concentration in multiple cells and cell fragments. It Identify factors that 2. Monitor and  To have a engaged in
fainted” the blood carries oxygen from the lungs and improve circulation record vital baseline data behaviors and
nutrients from the gastrointestinal signs actions that
Objective: tract. The oxygen and nutrients Identify necessary 3. Assess  To note any improve tissue
- Skin and subsequently diffuse from the lifestyle and diet patient’s abnormal perfusion
conjunctiva are blood into the interstitial fluid and changes general findings
both pale then into the body cells. condition
- Clubbing of Insufficient arterial blood flow Engage in behaviors
fingers noted causes decreased nutrition and or actions to 4. Encourage  To conserve
- Abdomen not oxygenation at the cellular level. improve tissue quiet and energy and
distended Decreased tissue perfusion can be perfusion restful lower tissue
- V/S taken as temporary, with few or minimal atmosphere oxygen
follows: consequences to the health of the Maintain maximum demands
BP: 110/70 mm patient, or it can be more acute or tissue perfusion to 5. Encourage  To enhance
Hg protracted, with potentially vital organs, as early venous return
T: 37.8 ˚ C destructive effects on the patient. evidenced by warm ambulation
P: 110 bpm When diminished tissue perfusion and dry skin, once tolerated
R: 24 cpm becomes chronic, it can result in present and strong 6. Discourage  To improve and
 tissue or organ damage or death. peripheral pulses, sitting/standing facilitate good
vitals within for long circulation
Source: patient’s normal periods
https://nurseslabs.com/ineffective- range and alert LOC 7. Instruct patient  To conserve
tissue-perfusion/ to avoid energy
strenuous
activities
8. Instruct  To help increase
patient’s SO Hgb count
about food rich
in iron
9. Regulate IVF as  To maintain
ordered hydration
10. Promote  To provide
adequate bed adequate
rest wellness

Dependent:
1. Administer  To keep the
medication patient and his
(Ferrous condition well-
sulfate, etc.) treated
Collaborative:
1. Collaborate  To ensure client
with a dietician is taking foods
regarding the that are rich in
patient’s diet iron

ASSESSMENT NURSING SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

(Subjective and DIAGNOSIS
Objective)
Subjective: Fatigue related Iron Deficiency Anemia-a condition in Within our care, client will Independent: Client/caregivers
“I feel so tired to decreased which blood lacks adequate healthy reduce and possibly eradicate 1. Assist the  Allows the will verbalize
and exhausted hemoglobin red blood cells. Red blood cells carry fatigue: client in planning client to reduction of
all the time” and oxygen to the body's tissues due to of daily living maximize his fatigue, as
diminished insufficient iron Identify the possible cause of activities time for evidenced by
Objective: oxygen- the said condition accomplishing reports of
- Pale skin and carrying Source: important increased energy
conjunctiva capacity of the https://www.mayoclinic.org/diseases- Verbalize understanding on activities and ability to
- Clubbing of blood conditions/iron-deficiency-anemia/ the need for energy while perform desired
fingers symptoms-causes/syc-20355034 conserving practices/activities providing activities.
- V/S taken as and schedule time to rest
follows: and to Client’s vital signs
BP: 110/70 mm conserve will be within
Hg energy. normal limits
T: 37.8 ˚ C
P: 110 bpm 2. Educate  To help client
R: 24 cpm energy- manage and
conservation conserve his
techniques. energy

3. Assist client in  Organization

developing a of activities
schedule for daily and time
activity and rest. management
Stress the can help the
importance of client
frequent rest conserve
periods energy and
reduce
fatigue.

4. Monitor  Decreased
hemoglobin, RBC indexes
hematocrit, RBC are
counts, and associated
reticulocyte with
counts. decreased
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.