NCP # 2: Ineffective tissue perfusion (GI) related to inadequate hemoglobin

concentration in blood.

ASESSMENT

NURSING

GOAL AND

NURSING

EVALUATION

DATA

DIAGNOSIS

OBJECTIVES

INTERVENTION

(Subjective

(Problem and

S AND

and

Etiology)

RATIONALE

Objective)
Ineffective

INDEPENDENT:

Subjective:

tissue

Short term

perfusion (GI)

Goals:

health

Goals:

related

After

teaching

Goals met.

inadequate

45minutes of

about

After

Abnorma

hemoglobin

thorough

necessity

45minutes of

concentration

nursing

of

thorough

increase

in blood.

intervention,

participati

nursing

of BP of

the client will

ng

intervention,

130/90

be able to:

these

the client was

Establi

identified

be able to

sh a

activities.
R To

establish a

Objective:

mmHg.
Abnorma
l
decrease
of bowel
sounds

(3 clicks)
Restless

to

blood
pressu
re
within
the
normal
range
(90/60

120/80

1. Provide

gain

Short

the

of

full

cooperati
on of the
client

in

improvin
g
circulatio
n.
2. Assist

term

blood
pressure
within the
normal range
(120/80mmH
g),
demonstrated
behaviors/life
style changes
to improve

mmHg

client

)
Demon

early

and

ambulatio

verbalized

strate

n.
R-

willingness to

behavi
ors/life

ambulati

style

on

chang

promote

es to

venous

improv

return.

on

Early
will

participate in
behavioral
changes.
Long term
Goals:

3. Assist

After 16 hours

circula

client

tion.
Verbali

doing

nursing

passive

intervention,

ze
willing

in

range

of

ness to

motion.
R Help

partici

in

pate in

promotin

behavi

g venous

oral

return.

chang
es.

after

meals.
R
to

Goals:

maximize

After 16 hours

blood

of thorough

flow

nursing

stomach,

intervention,

enhancin

the client will

be able to:

digestion

Mainta
in

the client was

able to
maintain

.
5. Elevate

pressure on
its normal
range

4. Encourage
rest

of thorough

blood

Long term

circulation

to

(120/80mmH
g) and
improved
bowel sounds
from 3 clicks.

blood

the

pressu

extremitie

re on

its

the

normal

cardiac

range

reserve.
R To

(90/60

120/80
mmHg

)
Improv
e bowel

lower
within

promote
effective
venous
return.
INDEPENDENT:

sounds

1. Administer

from 3

Ferrous

clicks

Sulfate

to 5

20mg

PO

clicks.

every

hours.
R - Iron
supplem
ents

in

the
productio
n

and

maturati
on

of

RBC.
1. Perform
blood
transfusio
n 1 unit of
PRBC 450
ml.

To

replace
loss

of

blood
within
the body.

ADPIE
Assessm

Diagnosi

Inferenc

ent
SUBJECTIV
E: Nanghi
hina
pa
ako.
as
verbalized
by
the
patient.

s
Fatigue
related to
altered
body
chemistry,
side effects
of pain and
other
medication
s,
chemother
apy

e
Rectal
cancer is a
disease in
which
normal
cells in the
lining of the
rectum
begin to
change,
start
to
grow
uncontrolla
bly, and no
longer die.
These
changes
usually
take years
to develop;

OBJECTIVE:
Lethargy
V/S taken
as follows:
T: 36.5 P:
90 R: 22
BP: 130/90

Planning
After

hours

of

nursing
interventio
ns,

the

patient will
report
improved
sense
of energy

Interven

Rational

Evaluati

tion
Have
patient rate
fatigue,
using
a
numeric
scale,
if possible,
the time of
day when it
is
most
severe.
Plan care to
allow rest
periods.
Schedule
activities
for periods
when
patient has
most

e
Help
in
developing
a plan for
managing
fatigue.
Frequent
rest periods
or naps are
needed to
restore or
conserve
energy.
Planning
will allow
patient to
be active
during
times when
energy
level
is

on
After
8
hours
of
nursing
interventio
ns,
the
patient was
able
to
report
improved
sense
of energy.

however, in
some
cases
of heredita
ry disease,
changes
can occur
within
months to
years. Both
genetic
and
environme
ntal factors
can cause
the
changes.
Initially, the
cell growth
appears as
a
benign(non
cancerous)

energy.
Assist
patient
with
selfcare needs.
Keep bed
in
low
position
and assist
with
ambulation
.

higher,
which may
restore
feeling of
well being
and
a
sense
of control.
Weakness
may make
activities of
daily
living and
ambulation
difficult,
further
assistance
is needed.