5ncp anemia

8/3/2019 5ncp Anemia

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XIII. NURSING CARE PLAN

CUES NSG. DIAGNOSIS GOAL NSG.INTERVENTION

RATIONALE EVALUATION

Subjective:Nahihirapan akohuminga, asverbalized by theclient.

Objective:RR= 31PR= 97BP= 130/90Nasal flaring(+) pallor in nailbeds

Impaired gasexchange related to

altered oxygen carrying capacity ofblood as evidenced

by increasedrespiratory rate.

After 8 hours ofnursingintervention, theclient willdemonstrateimprovedventilation and

absence ofsymptoms ofrespiratorydistress

Independent:

Elevate head ofbed/position clientappropriately;provide airwayadjuncts and

suction, asindicated.

Encourageadequate rest andlimit activities towithin clienttolerance.Promote calmand restful

environment.

Providepsychologicalsupport, active-listenquestions/concerns.

To maintain airway.

Helps limit oxygenneeds/consumption.

To reduce anxiety

Goal met. After

8 hours of

nursing

intervention, the

client was able

to demonstrate

absence ofsymptoms of

respiratory

distress


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Minimize bloodloss from

procedures (e.g.tests)

Dependent:

Administermedication asindicated (e.g.antibiotics)

To limit adverse

effect of anemia

To treat underlyingcondition



Subjective:Nahihirapan akohuminga, asverbalized by theclient.

Objective:RR= 31BP= 130/90Nasal flaring(+) Hematuria(+) EdemaHg level= 11.1gm/dlCapillary refill= 4

Ineffective tissueperfusion related to

decreasedhemoglobin level

concentration in bloodas evidenced by

increased respiratory

rate and lowhemoglobin level.

After 8 hours ofnursingintervention, theclient willdemonstrateincreasedperfusion as

individuallyappropriate.

Independent:

Monitor vital signs

Check for calftenderness

Elevate HOB andmaintain head inneutral position

Encourage quiet,restfulatmosphere

To assess baselinedata

Which may indicatethrombus formation

To promotecirculation

To conserveenergy/ lowerstissue oxygendemand

Goal partially

met. After 8

hours of

nursing

intervention,

the client was

able to partiallydemonstrate

increased

perfusion.


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Caution client to

avoid activitiesthat increasecardiac workload

Dependent:

Administermedications withcaution

Administerdiuretics

Collaborative:

Assist withtreatment of

underlyingcondition (e.g.medication, fluidreplacement)

To lower tissue

oxygen demand

Drugs used toimprove tissueperfusion also carryrisk of adverse

responses

To decrease edema

To improve tissueperfusion




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Subjective:nakakatayo

naman akokunwarimagbabanyoganun pero dahandahan lang kasimabilis akomapagod asverbalized by theclient.

Objective:-weak inappearance-decreasedhemoglobin:-BP: from 130/90mm Hg to 120/90-HR: from 97 bpm

to 84 bpm

Activity Intolerancerelated to decreased

hemoglobin asmanifested by

decreasedhemoglobin

After 8 hrs. ofnursing

intervention theclient will showincrease senseofindependencetowardactivities.

-Assess clientsability to stand

and move aboutand degree ofassistancenecessary/ use ofequipment.

-increaseexercise/activitylevel gradually.

-provides positiveatmosphere,whileacknowledgingdifficulty of thesituation for theclient.

-assist client withactivities.

-promoteindependence inself-care activitiesas tolerated.

-encourage clientto maintain

-to determinecurrent status and

needs associatedwith participation inneeded/desiredactivities.

-to conserveenergy.

-helps minimizefrustration andrechannel energy.

-to protect clientfrom injury.

-to enhance clientsability to participatein activities.

-to enhance senseof well-being.

Goal met.


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positive attitude;suggest use of

relaxationtechniques.

-Provide referralto otherdisciplines, suchas exercisepsychologist,psychologicalcounseling/therap

y, and physicaltherapist, asindicated.

-to developindividuallyappropriatetherapeuticregimens.

CUES DIAGNOSIS GOAL INTERVENTION RATIONALE EVALUATION

Subjective:sabi nila naninilawako as verbalizedby the client.

Objective:-jaundice

Disturbed bodyimage related to

jaundice asmanifested by

negative feelingabout oneself

After 2 hrs. ofnursingintervention theclient will

verbalizeacceptance ofself-situation.

-evaluate level ofclientsknowledge andanxiety related to

situation, observeemotionalchanges.

-listen to clientscommentsresponses to thesituation.

-which may indicateacceptance or non-acceptance ofsituation.

-different situationsare upsetting todifferent people,depending onindividual coping

Goal met.


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-discuss concernsabout fear ofmutilation,prognosis, andrejection.

-alert staff tomonitor own facialexpressions and

other nonverbalbehaviors.

-involve patient inplanning care andschedulingactivities.

-assist withgrooming needsas necessary.

skills and pastexperiences.

-To addressrealities andprovide emotionalsupport.

-because they needto conveyacceptance and not

revulsion when theclients appearanceis affected.

-enhance feeling ofcompetency /self-worth, encourageindependence andparticipation intherapy.

-maintainingappearanceenhances self-image.

CUES DIAGNOSIS GOAL INTERVENTION RATIONALE EVALUATION


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Subjective:

Ano na bangnangyayarisaakin?, asverbalized by theclient.

Objective:

-Confusion-Exaggeratedbehaviors

Deficientknowledge

related tounfamiliarity with

informationresources asmanifested byinappropriate

behaviors

After 8 hours ofnursing

intervention, theclient willverbalizeunderstanding ofcondition/diseaseprocess andtreatment

Determine clientsability/ readiness

and barriers tolearning

Provide positivereinforcement

Provide informationrelevant only to thesituation

Use short, simplesentences andconcepts

Provide active rolefor client in learningprocess

Use gestures andfacial expressionsthat help conveymeaning andinformation

To assess clientsemotional and

mental capability

To encouragecontinuation ofeffort

To preventoverload

To facilitatelearning

Promotes sense ofcontrol oversituation and ismeans fordetermining that

client isassimilating/ usingnew information

To facilitatelearning

Goal met. After 8

hours of nursing

intervention, the

client was able to

verbalize

understanding of

condition/disease

process and

treatment


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5ncp anemia

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