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Cues

Nursing Diagnosis

Justification

Desired outcome

Nursing interventions

Rationale

Evaluation

Subjective: Activity intolerance Galingin akon ulo related to bed rest as kag nakapoy gid akon evidenced by napamatyag. decrease in Verbalized by the hemoglobin and patient. erythrocyte

Decreased RBC and hgb

Independent: After 8 hours of -Monitor vital signs

-To obtain baseline data -to protectclient injury from

Decrease oxygencarrying capacity.

Objective: Weakness Pallor Source: Hgb: 74gms/Li Nurses Pocket Erythrocyte Volume Guide Fraction: .22li/Li Author: Marilynn E. Risk Factors: Doenges et al. Financially unstable Strengths: Family support and compliance to medication regimen.

Definition: Insufficient physiological or psychological energy to endure complete required or desired daily activities.

Tissue hypoxia -pallor -weakness -fatigue -dizziness

nursing intervention the patient will be able to: a. use identified techniques to enhance activity tolerance. b. identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible. c. demonstrate a decrease in physiological signs of intolerance. d. Increase of hemoglobin and erythrocyte volume concentration.

-assist client in walking, going to the bathroom and doing ADL. -encourage client to maintain positive attitude. -schedule rest period -instruct client to sit down while bathing and changing clothes.

Goal met.

Partially

The client was able to increase -to enhance sense of well hemoglobin being 105 gms/Li and erythrocyte -to save energy. volume fraction -to save energy and 31 li/Li and was able to sit alone but walks Dependent with assistance. 1. Transfuse Fresh -to increase RBC and Report Whole Blood hemoglobin level. dizziness and 450cc x 15-20 fatigue.
drops per minute as advised. 2. Administer -An antigout, to decrease allopurinol uric acid level. 300mg. Once a day as prescribed.

Collaborative 1. Request for -to determine cause of CBC, ECG, illness. ultrasound, elecrtolyte, chest xray.

Cues Subjective:

Nursing Diagnosis

Knowledge deficit related to unable to Wala man ko ya perceive problem as galaum nga muni ang severe. matabo sakon. As verbalized by the Definition: patient. Absence or deficiency of cognitive Objectives: information related Doubtful of to specific topic lack medicalprocedure and of specific always ask questions information necessary for client to make informed Risk Factors: choices regarding Financial incapability condition treatment No regular check up and lifestyle changes. Stregths: Source: Family Nurses Pocket Compliance to Guide medication Author: Marilynn E. Doenges et al.

Desired outcome After hours of nursing intervention the client will be able to: 1.verbalize understanding of disease process treatment regimen and limitations.

Nursing interventions Independent: 1. determine client ability readiness and barriers to learning.

rationale

Evaluation

-to assess readiness to learn Goal met and individual learning needs. The client was able to understand its disease and 2. Use short simple -to facilitate learning able to comply with the sentences and concepts diagnostic test and repeat and summarize as medications advised. needed. -to comply with the treatment and treat underlying cause of the disease.

2.participate in 3.Explain the disease to learning process. the client and the medications required. 3.identify signs and symptoms requiring medical evaluation.

Cues

Nursing Diagnosis

Justification

Desired outcome

Nursing interventions Independent:

Rationale

Evaluation

Subjective: Natamaran ko mag kaon, wala gid ko gana. Verbalized by the patient.

Objective: Weight: 39.5kgs Body weakness Consumed 10% of Definition: the meal served Intake of nutrients insufficient to meet Risk Factors: metabolic needs. Financial incapability Source: Nurses Pocket Strengths: Guide Family support and compliance to Author: Marilynn E. medication. Doenges et al.

Imbalanced nutrition less than body Decreased appetite requirements related to loss of appetite as evidenced by weakness,loss of Nutritional needs muscle tone and not met. weight inappropriate to age. Unintentional weight loss

After hours of nursing intervtion of laboratory 1.identify if the client -to assess causative/ entions the patient will at risk for malnutrition Contributing factors be able to: 2.assess weight. -to evaluate degree of -emphasize deficit. a.demonstrate 3.Encourage the client -topromote wellness. progressive weight gain to eat and discuss the toward goal. importance of well b. display normalization balanced nutrition. of laboratory values and 4.evaluate total daily -to establish a nutritional be free of signs of food intake plan that meets individual malnutrition as reflected needs. in defining characteristics. c. demonstrate Dependent behaviors lifestyle 1. Administer -to prevent infection. changes to regain and or levofloxacin maintain appropriate 500mg. 1 weight such as eating tablet per orem 100% of the meal served. 2. Give -An antisecretory omeprazole 40 compound that is a mg. IVTTonce gastric acid pump a day inhibitor. Suppresses Gastric acid secretion. Collaborative 1. Diet as -to sustain nutritional tolerated avoid demands. dark colored foods.

Goal partially met The client was able to eat 50% of meal served and weakness is lessen.

Cues

Nursing Diagnosis Ineffective tissue perfusion related to decreased hemoglobin concentration in the blood as evidenced by capillary refill: delayed by 4 seconds, pallor, restlessness, change in vital signs.

Rationale

Outcome criteria After hours of nursing Intervention the patient will be able to: a. Verbalize understanding of condition, therapy regimen. b. Demonstrate lifestyle changes to improve circulation. c. Demonstrate increase perfusion as evidenced by capillary refill of 2 seconds, absence of pallor and able to do ADL.

Nursing Interventions Independent: Assess contributing factors.

Rationale

Evaluation

Subjective: Galingin akon ulo kag nakapoy gid akon napamatyag. Verbalized by the patient.

Decreased RBC and hgb

Decrease oxygencarrying capacity.

Objective: Weakness Pallor Dizziness Eady fatigue BP: 150/100mmhg

Definition: Decrease in oxygen resulting in the failure to nourish the tissue at the capillary level.

Tissue hypoxia -pallor -weakness -fatigue -dizziness -lethargy

Asses skin for coolness, pallor, cyanosis, diaphoresis and delayed capillary refill. Maintain adequate fluid intake and monitor urine output.

Risk Factors: Financially unstable Stength: Follows doctors advised and compliance to medication.

Source: Nurses Guide

Pocket

Author: Marilynn E. Doenges et al.

Maintain environmental temperature and body warmth. Scedule rest peiod and sleep.

Goal partially Evaluate for signs and met. symptoms especially when immune system is The patient was compromised. able to understand his Changes reflect diminished current illness, perfusion to the CNS due to there is a ischemia or infraction. decrease in blood pressue and increase in Dehydration not only RBC and hgb causes hypovolemia but level. increases sickling and occlusion of capillaries. Decreased renal perfusion and failure may occur because of vascular occlusion. Prevents vasoconstriction, aids in maintaining circulation and perfusion. to lower pressue. down blood

Dependent: 1. Transfuse Modified Pack RBC 450cc x 15-20 drops per minute.

-to increase RBC and hemolobin level.

2. Give nifedipine 5 mg sublingual every 6 hous for BP >150/100mm hg.


3. Administer oxygen inhalation 2LPM as advised Collaborative: Review results of diagnostic studies such as CBC, Ultrasound, electolytes, clotting time, prothombin time.

-to lower down blood pressure

-for supplemental oxygen.

To determine location and severity of condition and treat underlying cause.