NURSING SCIENTIFIC NURSING

CUES OBJECTIVES RATIONALE EVALUATION

DIAGNOSIS RATIONALE INTERVENTIONS
Subjective: Activity Anemia caused by STO: INDEPENDENT: After 6 hours of
intolerance related bleeding, iron and other After 6 hours of nursing . nursing intervention
““Ginkakapoy to anemia as components of the intervention the client 1. Assess client’s ability to 1. Influences choice of the client was able
gad ako permi evidenced by erythrocyte are lost from will be able to: perform normal tasks interventions and to:
bisan dire man fatigue and the body. Blood loss  Report a measurable and ADLs, noting needed assistance.  Report a
damo tak generalized may be acute or chronic. increase in activity reports of weakness, measurable
ginbubuhat. weakness Acute blood loss carries a tolerance, including fatigue, and difficulty increase in
Bisan risk for hypovolemia and performance of accomplishing tasks. activity
nagliliningkoron shock. The red cells are ADLs. tolerance,
la ako, dire la normal in size and color.  Demonstrate 2. Note changes in 2. May indicate including
nag-iiha A fall in the red blood cell reduced balance, gait neurological performance of
ginkakapoy count, hematocrit, and physiological signs disturbance, and changes associated ADLs.
dayon ako.” As hemoglobin are caused of intolerance – muscle weakness. with vitamin B12  Demonstrate
verbalized by the by hemodilution resulting pulse, respirations, deficiency, affecting reduced
client. from movement of fluid and BP within client safety and physiological
into the vascular client’s normal range increasing risk of signs of
compartment. If the injury. intolerance –
Objective: bleeding is controlled and LTO: pulse,
sufficient iron stores are After 1 week of nursing 3. Monitor BP, pulse, and 3. Cardiopulmonary respirations,
 Hg: 94 g/L available, the red cell intervention the client respirations during and manifestations and BP within
 Hct: 0.31 concentration returns to will be able to: after activity. Note result from attempts client’s normal
 MCV: 72.50 normal within 3 to 4  Display laboratory adverse responses to by the heart and range
 MCH: 21.8 weeks values (Hgb/Hct) increased levels of lungs to supply
 MCHC: 300 within acceptable activity— increased adequate amounts After 1 week of
Reference: range. heart rate and BP, of oxygen to the nursing intervention
Porth, C. M. (2004). dysrhythmias, tissues. the client was able
Pathophysiology - dizziness, dyspnea, to:
Concepts of Altered tachypnea, and  Display
Health States. Lippincott cyanosis of mucous laboratory
Williams & Wilkins. membranes and values
nailbeds. (Hgb/Hct) within
4. Activity may need to acceptable
4. Recommend frequent be curtailed until range.
rest periods or bedrest, severe anemia is at
as indicated. least partially
corrected to lower
body’s oxygen
requirements and
reduce strain on the
heart and lungs.
5. Enhances lung
5. Elevate head of bed, as expansion to
tolerated. maximize
oxygenation for
cellular uptake.

6. Postural
6. Suggest client change hypotension or
position slowly; monitor cerebral hypoxia
for dizziness. may cause
dizziness, fainting,
and increased risk
of injury

7. Promotes adequate
7. Assist client to prioritize rest, maintains
ADLs and desired energy level, and
activities. Alternate rest alleviates strain on
periods with activity the cardiac and
periods respiratory systems

8. Although help may

8. Provide or recommend be necessary, self-
assistance with esteem is enhanced
activities and when client does
ambulation as some things for self.
necessary, allowing
client to be an active
participant as much as
possible. 9. Promotes gradual
return to a more
9. Plan activity normal activity level
progression with client, and improved
including activities that muscle tone and
client views as stamina. Increases
essential. Increase self-esteem and
activity levels, as sense of control.
tolerated
10. Encourages client
to do as much as
possible, while
10. Identify and implement conserving limited
energy- saving energy and
techniques: shower preventing fatigue
chair and sitting to
perform tasks. 11. Cellular ischemia
potentiates risk of
infarction, and
11. Instruct client to stop excessive
current activity if cardiopulmonary
palpitations, chest pain, strain and stress
shortness of breath, may lead to
weakness, or dizziness decompensation
occur. and failure

12. Vasoconstriction
with shunting of
blood to vital organs
12. Discuss importance of decreases
maintaining peripheral
environmental circulation,
temperature and body impairing tissue
warmth, as indicated. perfusion. Client’s
comfort and need
for warmth must be
balanced with need
to avoid excessive
heat with resultant
vasodilation, which
reduces organ
perfusion.

1. Identifies
COLLABAORATIVE deficiencies in RBC
components
1. Monitor laboratory affecting oxygen
studies, such as transport, treatment
Hgb/Hct, RBC count, needs, and
and arterial blood gases response to
(ABGs). therapy.
2. Maximizing oxygen
2. Provide supplemental transport to tissues
oxygen as indicated. improves ability to
function.

3. Increases number
3. Whole blood, packed of oxygen- carrying
RBCs (PRCs); blood cells; corrects
products (fresh- frozen deficiencies to
plasma [FFP], platelets, reduce risk of
blood factors) as hemorrhage in
indicated for the client’s acutely
particular needs. compromised
Monitor closely for individuals.
reactions during blood Transfusions are
transfusion. reserved for severe
blood loss anemias
with cardiovascular
compromise and
are used after other
therapies have
failed to restore
homeostasis

4. Vitamins help to
4. Vitamins such as correct deficiencies
cyanocobalamin (also and promote protein
called vitamin B12 synthesis.
[Ener- B, Calo- Mist]),
folic acid (Folvite), and
vitamin K
Source:
Doenges, M. E.,
Moorhouse, M. F., &
Murr, A. C. (2014).
Nursing Care Plans
(9th ed.). Philadelphia,
PA 19103: F. A. Davis
Company.