Republic of the Philippines

City of Olongapo
GORDON COLLEGE
College of Allied Health Studies
Bachelor of Science in Nursing
www.gordoncollege.edu.ph

A case study presented to the College of Allied Health Studies

Bachelor of Science in Nursing Gordon College

MEDICAL WARD AREA

CASE

“Anemia with Chronic Disease to consider Acute Myeloid Leukemia”

Submitted by:

Dimalanta, Mariah Krystiane S.

Edquiban, Akira Kenchie O.
Flores, Christine Joy

BSN III GROUP A6

FEBRUARY 18, 2023

 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
College of Allied Health Studies
Bachelor of Science in Nursing
www.gordoncollege.edu.ph

NURSING DIAGNOSIS JUSTIFICATION

1 Impaired gas exchange Impaired gas exchange is a disruption of the oxygen and
related to altered oxygen carbon dioxide exchange in the lung tissues. This nursing
carrying capacity of blood diagnosis can be a serious health threat usually closely
as evidence by reduction associated with other nursing diagnoses like ineffective
level of RBC breathing pattern or ineffective airway clearance.

2 Acute pain related to In our assessment, the patient has guarding behaviors and
physical agent as verbalized that he is experiencing sudden pain in certain
evidenced by reports of body areas especially in his upper extremities. It may cause
bone pain with guarding discomfort which may alter the body to heal effectively
behaviors

3 Activity Intolerance During the patient's hospitalization, it seriously affected his

related to Physical ADL performance, and decreased his capability to enhance
deconditioning as evidence his ability to work. It may cause limited ROM and muscle
of circulatory problems weakness.

4 Disturbed sleeping pattern The patient was exposed to late night working hours that led
related to to alterations in body processes that may cause decreased
environmental/work immune system to fight off current health problem
barriers

5 Ineffective Role Due to physical deconditioning client had limitations in

Performance physical activity and the client showed the presence of
health-alterations, change muscle atrophy in all of extremities.
in physical capacity.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
College of Allied Health Studies
Bachelor of Science in Nursing
www.gordoncollege.edu.ph

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIO RATIONALE EVALUATION

N

Subjective: Impaired gas Short Term Establish rapport It allows you Short Term
exchange Goal: to the patient to understand Goal met:
Relative related to your patient's
reported that After 30 feelings and After 30
ventilation
patient feels like minutes of communicate minutes of
drowning when perfusion Nursing well with Nursing
head not imbalance as Intervention, them. Intervention, the
elevated evidence by the patient patient maintain
reduction will be able to O2 Saturation
Headache upon level of RBC maintain O2 Obtain Vital signs This will serve within normal
awakening as Saturation Q4 as a baseline range and
verbalized by within normal data of the verbalized
the patient range and patient. All understanding
verbalize vital signs are of appropriate
Objective: understanding impacted by interventions
of appropriate changes in
Received interventions oxygenation.
patient in
oxygen therapy
using nasal Long Term Note the presence To assess Long Term
cannula Goal: of factors and causative Goal met:
refer to ND’s factors. Gas
Vital Signs: After 1 - 2 pattern as exchange After 1 - 2
BP: 110/60 hours of appropriate problems can hours of
Tempt: 36.5 Nursing be related to Nursing
Intervention multiple Intervention the
PR: 116
the patient factors, patient maintain
RR: 26 will be able to including and participate
O2: 97 maintain and anemias. in adequate
participate in treatment
Hemoglobin: 27 adequate regimen within
Below average treatment Assess the level A decreased level of ability
value regimen of consciousness level of ● Breathin
within level and mentation consciousness g
of ability changes can be an exercise
RBC: 0.74 ● Breath indirect s,
below average ing measurement ● Use of
value exerci of impaired oxygen
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
College of Allied Health Studies
Bachelor of Science in Nursing
www.gordoncollege.edu.ph
ses, oxygenation ● Proper
Patient seen as ● Use of intake of
Pallor oxyge Note client That would be medicati
n reports of associated with on as
Presence of ● Proper headaches diminished ordered
general intake arising. Assess oxygenation. by the
atrophy of energy level and physicia
medic activity n
ation intolerance, ● Strictly
as noting evidence NPO
ordere of fatigue, as
d by weakness and ordered
the problems with by the
physic sleep. physicia
ian n
● Strictl
y
NPO Evaluate pulse To determine
as oximetry oxygenation.
ordere
d by
the
physic Review other To evaluate the
ian pertinent degree of
laboratory data compromise.
(CBC)

Elevate the head Elevation or

of the bed and upright
position the client position
appropriately. facilitates
respiratory
function by
gravity.

Provide To help
supplemental correct/
oxygen at lowest improve
concentration existing
indicated by deficiencies.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
College of Allied Health Studies
Bachelor of Science in Nursing
www.gordoncollege.edu.ph
laboratory results
and client
symptoms or
situation.

Encourage This helps

adequate rest and limit oxygen
limit activities to needs and
within client consumption.
tolerance.

Monitor and Pharmacologic

instruct client in al agents are
therapeutic and varied, specific
adverse effects as to the client,
well as but generally
interactions of used to prevent
drug therapy and control
symptoms and
improve
tolerance.

Keep the To reduce the

environment irritant effect
allergen and of dust and
pollutant free chemicals on
airways.

Discuss To reduce
implications of health risks
smoking related and prevent
to the illness or further decline
condition in lung
function.
 Republic of the Philippines
City of Olongapo
GORDON COLLEGE
College of Allied Health Studies
Bachelor of Science in Nursing
www.gordoncollege.edu.ph

Emphasize the Improves

importance of stamina and
nutrition reducing the
( The patient is work of
advised to have breathing
general liquid
diet due to
underlying
condition as
ordered by the
physician)