NCP Autoimmune Hemolytic Anemia
ASSESSMENT NURSING DIAGNOSIS
(Differentiate OBJECTIVE
from SUBJECTIVE DATA)
SUBJECTIVE DATA:
Meredith is married with a 5-
year-old son. Works as an
accountant in a bank.
Meredith reported that she
had normal childhood
illnesses of chickenpox and
mumps but denied any
complications or prolonged
illnesses or injuries. She
denied any known family
history of lupus, rheumatoid
arthritis and other rheumatic
conditions.
Patient reported that her
current level of fatigue is
challenging her as she was
always active and energetic
before her miscarriage. She
described needing to rest after
PLAN INTERVENTIONS RATIONALE EVALUATION
(Actual or Potential with (Include Long and Short (At least 5 and include (with scientific evidences (State whether met,
complete parts) Term Goals plus at least 3 only the MOST as needed) partially met or unmet
outcome criteria) APPROPRIATE for and the supporting
client’s context) outcomes)
FATIGUE related to NOC- Functional Health NIC- Health System GOAL MET:
Decreased Hemoglobin Guidance
and Diminished Oxygen- SHORT TERM:
Carrying Capacity of the
Blood After 8 hours of After 8 hours of Nursing
Nursing intervention the Assess the Specific Cause The specific cause of fatigue intervention:
Evidenced by: Patient will: of Fatigue is tissue hypoxia from
normocytic anemia; other  The Patient had a
related medical problems can normal CBC Count:
 Inability to  Be treated of the
also compromise activity
Maintain Usual underlying cause of tolerance.
Level of Physical anemia RBC: 4.5
Activity  Return to normal million/mm3
 Increased Rest counts of RCBs WBC: 5,000/mm3
Monitor Hemoglobin, Hgb: 14 g/dl
Requirements and HGB. Hematocrit, RBC counts Decreased RBC indexes are
associated with the Hct: 40%
 Report of Fatigue and Reticulocyte Counts
decreased oxygen-carrying Platelet Count:
and Lack of
capacity of the blood. It is 155,000/mm3
Energy
critical to compare serial
laboratory values to evaluate  Patient verbalized
the client’s progression or that the Nutritional
deterioration and identify Education was
changes before they become practiced. The
life-threatening. patient religiously
followed to avoid
her morning routine of Provide Nutritional intake of foods
showering, dressing and Education: High in Calcium and
fixing breakfast.  Increase Green increase Green
Leafy Vegetables Leafy Vegetables.
She also reported that she is  Incorporate Leafy Greens such as
only able to complete one or Foods High in Spinach, Kale, and Chard are
two other tasks like high in Iron and Folate.
Vitamin C
vacuuming, laundry or  Intake of red Vitamin C assists in the
dusting and she needed rest Meat, Lamb, absorption of Iron. Good
after. Poultry as well as choices include Oranges, red
Fish and Shellfish Peppers and Strawberries.
Meredith described her  Limit or Avoid
sleeping pattern: Difficulty Intake of Foods All Meats and most Fish and
Falling Asleep, waking after High in Calcium Shellfish contain Heme Iron.
2 to 3 hours followed by
difficulty returning to sleep Calcium-Rich Foods such as
for 1 to more hours after Raw Milk, Yogurt, Cheese
waking. She felt like her and Broccoli are high in
sleep is not restful when she Calcium, which binds with
gets out of bed in the Iron and prevents absorption.
morning.

She also noted that her lack

of sleep interferes with her
memory and coping abilities.

Meredith also described pain,

swelling and stiffness in her
joints progressing over the
past 4 months. She first noted
stiffness in her fingers in the
morning and after typing on
LONG TERM:
the computer. Assess the Patient’s
She also reported that 2
months ago she noticed
swelling in her fingers and
wrists. And in the past 2 to 3
weeks, she has noticed
swelling in her knee along
with difficulty rising from a
seated position. She described
the pain as intermittent which
was most notable in the
morning and after activity
that involves her hands and
knees.
Patient also reported that her
appetite remained decreased
after her morning sickness
subsided 2 ½ months ago.
She denied any type of rash
after sun exposure, but
reported that her arms and
tops of her feet itch after she
is under the sun without
sunscreen.
OBJECTIVE DATA:
After 1-2 weeks of Nursing Description of Fatigue:
Intervention the Patient Timing (Afternoon or All
will: Day), Relationship to GOAL MET:
 Verbalize Activities and
understanding on Aggravating and This information may be  The patient
the use of energy Alleviating Factors. helpful in developing exclaimed that she
conservation and organizing patterns can do the things
principles of activities that that she usually
 Verbalize optimize the times when does during the
reduction of the patient has the morning.
Determine whether  The patient
fatigue as greatest energy reserve.
Fatigue is related to scheduled her
evidenced by
Psychological Factors activities. She
reports on
(Stress, Depression). shared that she
increased energy
and ability to Fatigue is best treated by does the laundry at
perform desired determining the causative the morning and
activities. factor. Depression is a do the cleaning
 Attain or Maintain common problem for after having her
adequate Nutrition people suffering from lunch.
Chronic Disease,  The patient
especially when the reported that she
discomfort is an had enough energy
accompanying problem. to do her
Medications are available responsibilities at
that are successful in work and at home.
treating clinical  The patient also
depression. reported that she
Reinforce Energy- had kept the
Conservation Principles: advice of not
taking stimulating
 Adequate Rest foods and doing
Periods activities before
bedtime.
Physical Assessment:
 Pacing of
Height: 62” Activities (an
Weight: 106 lbs alternating Energy reserves may be
Temperature: 99.5 °F activity with rest) depleted unless the Patient
HR: 88 bpm respects the body’s need
RR: 20/min. Fatigue that is related to for increased rest.
BP: 110/70 Interrupted Sleep:
The Patient often needs
X-Rays:  Instruct the more energy than others to
Patient to Avoid complete the same tasks.
Hands, wrists and knees Stimulating Foods
showed soft tissue swelling (Caffeine) or
and no joint space narrowing Activities before
or bone damage. Bedtime.
Environmental Stimuli can
Complete Blood Count inhibit relaxation,
(CBC): interrupt sleep and
contribute to fatigue.
Red Blood Cells/ RBC: 4.0
million mm3

White Blood Cells/WBC:

3,950/mm3

Hemoglobin/Hgb: 11 g/dl

Platelet Count: 148,700/mm3

Mean Corpuscular
Volume/MCV: 86µm
Mean Corpuscular
Hemoglobin/MCH: 28 pg
Mean Corpuscular
Hemoglobin
Concentration/MCHC: 33
g/dl

Neutrophils: 62%

Lymphocytes: 28%

Monocytes: 7%

Eosinophils: 2%

Basophils: 1%

Chemistry Profile:

Alkaline Phosphatase:
25U/ml

Asparate Ammino
Transferase/AST: 28U/ml

Alanine Amino
Transferase/ALT: 22U/ml

Blood Urea Nitrogen/BUN:

25.5 mg/dl

Creatinine: 1.8 mg/dl

Sodium/NA: 138 mEq/L

Chloride/Cl: 104 mEq/L

Potassium/K: 4.2mEq/L

Carbon Dioxide/CO2:
25mEq/L

Phosphate: 3.9 mg/dl

Uric Acid: 3.1 mg/dl

pH: 7.42

Thyroid Panel:

Triiodothyronine/T3:
167ng/dl

Thyroxine/T4: 6µg/dl

Thyroid Stimulating
Hormone/TSH: 8µU/ml

ANA: Positive

ESR: 240 mm/hr

Submitted by: Evaluated by:

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