SAULT COLLEGE OF APPLIED ARTS AND TECHNOLOGY

Care Plan by JOIDA MAE ESPER I. CANONO IEN-ENP

Code Status: _DNR_

Oxygen: Room air O2 Sat: 98%
Admitting Diagnosis: Allergies: Codeine
Tubes: None Dressing: N/A
Coexisting Illness(es): Hypertension, Dyslipidemia, Schizophrenia/bipolar, Iron
deficiency anemia, Hepatitic C, previously treated, Substance use disorder, Isolation: None
intermittent ongoing use of crack cocaine and meth, COPD, GERD. Mobility: level C Lift/Transfer: Lift/Transfer DEPENDENT
VS: BP: 124/70, PR- 78, RR- 16, T- 36.6 Wt: 45.5 kg Level of Risk for Falls: Low
Diet: Regular IV: None LBM: 02/12/22 Other: with plan for trialing subcu hydromorphone prior care/ROM

ASSESSMENT PLANNING
Behaviour/Responses/Findings Nursing Interventions EVALUATION
Nursing AMB/AEB Goal
Diagnosis

Subjective: Fatifue related to -Exhaustion Patient will report an 1. Monitor CBC. Within 12 hour of
-with past medical Hx of decreased Inability to increase in energy and Assess the patient’s shift, patient Client
Adenocarcinoma of the lung hemoglobin and maintain physical ability to perform complete blood count verbalize reduction
with palliative radiation to diminished -activity tasks including red blood of fatigue, as
painful spine. oxygen-carrying Increased need count and hemoglobin evidenced by
-Hx of iron deficiency anemia capacity of the for rest levels. These will be reports of increased
blood. -Reported lack of low in anemic patients. energy and ability to
Objective: energy perform desired
-W= 45.4 kg. -Lethargy 2. Assess for chronic activities.
-inability to maintain physical conditions that worsen
activity anemia.
-lethargy Chronic conditions can
cause and contribute
Diagnostic work: WBC 12.4 to anemia. Treating the
HGB – 98, Hct – 0.323 L, MCV- underlying cause of
76 L, Plt count – 312. anemia should be a
priority.
V/s: BP: 124/70, PR- 78, RR- 16,
T- 36.6
3. Assess the extent of
fatigue in daily life.
Inquire about activities
the patient can or
cannot perform, the
effect it has on their
responsibilities and
roles, and how they
manage their
symptoms.

4. Instruct on energy
conservation.
Plan rest periods,
delegate tasks to
others, cluster
activities together,
prioritize activities
when energy levels are
highest.

5. Apply oxygen.
Patients being treated
for anemia in the
hospital may require
supplemental oxygen
for very low
hemoglobin levels.

6. Administer blood
transfusions.
If a patient is severely
anemic or has suffered
a blood loss causing
anemia, blood
transfusions may help
with fatigue.
7. Administer
erythropoietin
injections.
Epogen and Procrit are
two common injections
given that stimulate
the bone marrow to
produce red blood
cells. Patients with
cancer, HIV, or kidney
disease often have
severe anemia and
require these
injections.
 ASSESSMENT PLANNING

Behaviour/Responses Nursing Interventions EVALUATION

(data collection information and
Nursing Diagnosis AMB/AEB Goal
(including time frame)
observations)
Notes:

SBAR: