Assessment

S: Medyo
nahihilo at
nahihhirapan
ding huming at
tsaka madali
akong
napapagod.

Brief
Explanation of
the Problem
Anemia is a
symptom of an
underlying
condition, such as
loss of blood
components,
elements
inadequate or lack
of nutrients
needed for the
formation of red
blood cells,
resulting in
decreased oxygencarrying capacity
of blood (Doenges,
1999)

Goals and
Objectives
GOAL: The patient
will be able to have
an effective
peripheral tissue
perfusion

Objectives:
LTO: After 72 hours
O: Vital signs
nursing interventions
taken as: BP:
the patient will be
90/50mmhg.
able to have an
RR: ,PR:
effective tissue
,T: .
perfusion as
manifested by:
RBC Count:
a. Stable RBC,
3.85 x10^12/L
Hgb, Hct count
Hgb: 116 g/L
(within normal
Hct: 0.345.
levels)
b.
Absence of
Capillary refill
According to
signs and
of 2-3 seconds, NANDA, ineffective
symptoms of
conjunctival
peripheral tissue
anemia
pallor noted. On perfusion is the
CBR with BRPS
decrease in blood

Nursing
Interventions
Dx:
1. Monitor and
record Vital
Signs.

Rationale

Criteria for
Evaluation

LTO: After 72 hours

>serves as a baseline of nursing
data for any
interventions:
significant changes in
Fully met if;
the patients condition
a. The patient
have a stable
2. Reviewed
> Normal value s
RBC, HCT AND
laboratory
indicate adequate
Hgb within
studies such as tissue perfusion.
normal levels
b.
Absence of
hemoglobin
Indicates Effectiveness
signs and
,hematocrit
of nursing
symptoms of
and RBC
interventions.
anemia
Partially met if:
3. Assess patient
a. RBC, Hct and
general
> To have a baseline
Hgb increased
condition
data and note any
but not within
abnormal findings.
normal levels
Tx:
b. Still with
Anemia
4. Administered
Not met if:
> It replenishes iron
Sangobion itab stores in the body and
a. RBC, Hct, and
TID
corrects hemoglobin
Hgb remains

P1: Ineffective
tissue perfusion
related to
decrease in
hemoglobin
secondary to
anemia

circulation to the
periphery that
may cause
compromise
health.
Reference:
Doenges, M.E.
(2010). Nurses
Pocket Guide.
Diagnoses,
Prioritized
interventions and
Rationales. F.A.
Davis Compay.
Philadelphia. Pp.
608-614

STO: After 8 hours of

nursing interventions
the patient will be
able to:
a. Have an
increase in
RBC, Hct and
Hgb within
normal levels.
b. Have an
adequate tissue
perfusion as
manifested by
capillary refill of
1-2 seconds, no
pallor
c. no difficulty of
breathing, no
easy fatigability
and dizziness.

deficit by increasing
hemoglobin levels

5. 1 unit PRBC
transfused

6. Administer IV
fluids as
ordered.
7. Maintain on
bedrest

8. Provide safety
by raising side
rails

9. Provide
supplemental
oxygen as
indicated.

> Maintain and

increase circulating
blood volume to
maximize tissue
perfusion

> Maintain and

increase circulating
volume to maximize
tissue perfusion
> Restricted activity
reduces oxygen
demands of the heart
and other organs.
> Weakness, fatigue
and restlessness are
signs of hypoxia which
may cause injury to
the patient.
> to maximize the
transport of oxygen to
tissues.

the same
level and no
increase.
b. Still with
Anemia
STO: after 8 hours
of nursing
intervention:
Fully met if:
a. Have an
increase in
RBC, Hct and
Hgb within
normal levels.
b. Have an
adequate
tissue
perfusion as
manifested by
capillary refill
of 1-2
seconds, no
pallor
c. no difficulty of
breathing, no
easy
fatigability

and dizziness.
Edx:
Partially met if:
a. Have an
10.
Encourag
increase in
e quiet and
> To conserve energy and
RBC, Hct and
restful
lower tissue oxygen
Hgb within
atmosphere
demands.
normal levels.
b. Have an
adequate
11.
Instructe
tissue
d to avoid
>Straining further
perfusion as
straining
needs an increase in
manifested by
oxygen demand
capillary refill
12.
Taught
of 1-2
on proper DBE >Promotes lung
seconds, no
expansion and
pallor
increase
O2
supply
in
c. Still with
13.
Eat foods
the body
minimal
rich in iron
>To increase the
difficulty of
except raw and capacity of the RBC to
breathing,
uncooked fruits carry O2 in the body,
easy
and vegetables except raw foods since
fatigability
the patient has a
cancer, unseen
and dizziness.
bacteria in raw foods
might compromise the Not met if:
patients status.
a. No
improvement
in general
condition

References:
Doenges, M.E. (2010). Nurses Pocket Guide. Diagnoses, Prioritized interventions and Rationales. F.A. Davis Compay. Philadelphia.
Pp. 608-614
Drug Study. (2010). Retrieved by http://www.studymode.com/essays/Drug-Study-527723.html

Cues
Subjective:
mas madali
akong kapitan
ng sakit
ngayon kaysa
dati
Objective:
Immunucompr
omised
-Skin warm to
touch
-BMI: 16 kg/m2
(underweight)
-decreased in
appetite
having 75 %
Vital sign of :
Bp=90/60
mmhg
PR-80bpm
RR-24 cpm
Temp36.4 C

Explanation
of the
problem
The immune
system is
protects the
body against
disease or
other
potentially
damaging
foreign
bodies. It
identifies a
variety of
threats,
including
viruses,
bacteria and
parasites,
and
distinguishes
them from
the body's
own healthy
tissue. When
the immune
system is
compromise
d, there is
greater risk
for infection

Goals and
Objectives
Short term
objective:
After 8 hours of
nursing
intervention, patient
will:

-Laboratory

Dx
-Assess Vital signs
like temperature

a. have decrease

signs of
infection as
manifested by
improved
Laboratory
result :
1.Laboratory
result of
RBC=4.0-5.5
HCt=0.370.47g/l
WBC=4.1 10.9
g/L)

-Assess all systems:

skin, respiratory,
genitourinary for signs
and symptoms of
infection on a
continual basis

- Review lab results

specifically CBC with
After 3 days of
RBC, differential WBC
nursing
intervention, patient and granulocyte
count, and platelets as
:
Long term Objective

In the
patients
case ,her
immune
system

Intervention

Rationale

-Temperature
elevation may
occur ,if not masked
by corticosteroids or
anti inflammatory
drugs because of
various factors
including side effect
of
chemotherapy
,disease process of
infection.Early
identification of
infectious process
enables appropriate
therapy to be started
promptly.
-Early recognition
and intervention
may prevent
progression to more
serious situation
such as sepsis.

Evaluation
STO is fully Met since
the patient had :
decrease signs
of infection as
manifested by
improved
Laboratory
result :
1.Laboratory
result of
RBC=4.0
HCt=0.37
WBC=4.1 g/L)
LTO is fully met since
the
Hadbeen free from
signs of infection as
manifested by:
1.Normal
Laboratory
result of
RBC=4.5
HCt=0.46g/l
WBC=9.0 g/L)

2.improved .BMI
of 16.5 to 20.5
3.Increased
appetite by
consuming
foods of 75 % to

References : Lippincott Williams & Wilkins (2006) Nursing 2006 Drug Handbook 26th edition,
Black, J., Hawks, J.,Keene, A.,(2006) Medical-Surgical Nursing Clinical Management for positive outcomes, 6th edition
Ignaviticus ,D., (2006) Medical Surgical Nursing Critical Thinking for Collaborative Care ,5th edition
Doenges,M.,(2010)Nursing Care Plans,Guidelines for Individualizing Client Care Across the Life Span,8 th edition