LA CONSOLACION UNIVERSITY OF THE PHILIPPINES

Malolos, Bulacan
COLLEGE OF MEDICINE AND ALLIED MEDICAL PROFESSIONS

NURSING CARE PLAN

Patient’s Initial: J . F Age: 33 years old Gender: Female Date Handled: MARCH 28, 2023

Medical Diagnosis: Anemia Chief Complaint: Dizziness, Paleness, and weakness Clinical Area: Wards

Assessment Nursing Diagnosis Panning Intervention Rationale Evaluation

Subjective: Iron Deficiency: related to Short Term Goal: Independent: Short Term Evaluation:
low red blood cells also
“Madalas akong nang lalata at After 8 Hours of • Make rapport • To gain trust from the After 24 to 48 hours of the
nahihilo” as verbalized by known as hemoglobin that
implementing the patient to be nursing interventions the
patient. contains of iron supply as
intervention the patient comfortable in goal was:
evidence by having
will ease the feeling of communicating and
fatigue, pallor, and ✓ .Met
dizziness and being pallor performing the
Objective: generalized weakness.
interventions. .Partially met
Long Term Goal:
The patient is paleness and
.Not met
weakness. After one week of the • Assess the client’s • To identify the needed
nursing intervention the ability to perform the assistance of the As evidence by:
Blood Pressure: 100/70 mmHg
patient will be able to normal task and note patient.
Temperature: 37 1. Normal vital
maintain the iron supply the ADL’s.
signs.
Pulse rate: 78 on her body as evidence
2. Normal laboratory
by: • Monitor the vital • To monitor the
O2 Saturation: 99 level such as RBC
signs. abnormal changes that
1. Normal blood and hemoglobin.
Respiratory Rate: 19 o BP may be brought by the
pressure 3. Demonstrate the
o PR disease.
2. Normal red blood tolerance in
o O2 Saturation
cell level and performing ADL’s
o Temperature
hemoglobin level.
 3. Normal activity o RR
tolerance.
4. Knowledgeable for • Give her diet that are
taking iron rich in iron. (lean
supplement. meat, fish, beans,
leafy greens)
• Provide a health and
nutritional education.
Dependent:
• Follow the physician
order of
administering
medication through
IV and oral.
Collaboration:
• If the Doctor’s order
to refer the patient to
hematologist doctor
to check the blood
level and results.
Student’s Name: Chielee Anne A. Payongayong Yr&Sec/Group No. 2B Group #7 Clinical Instructor: Professor Ma. Katrina Dela Cruz
. Long-Term Evaluation:
After 1 month of the
• To have an iron supply
nursing intervention the
that will bring back the
client’s will be able to
normal level of
maintained the normal
hemoglobin.
level of her laboratory
such as RBC and
• To have knowledge in
hemoglobin to increase
her disease and in
her iron supply.
foods that will help her
to prevent in iron
deficiency.
• To treat the patient
accordingly.
• To identify the level of
RBC and hemoglobin.