Assessment Diagnosis Planning Intervention Rationale Evaluation

March 25, 2019 Ineffective At the end of 8 hours, 1. Monitored and Record To have a baseline data Goal met
peripheral tissue the patient will be able Vital Signs
Objective: perfusion r/t to: At the end of 8 hours,
BP: 100/50 mmHg anemia 1. maintain vital signs 2. Assessed patient’s To have a baseline data and the patient was able to:
RBC: 4.05 x10^12/L within patient’s normal general condition note any abnormal findings 1. maintain vital signs
(4.5-5.5 x10^12/L) limits within patient’s normal
HGB: 12.2 g/L (13-18 3. Encouraged quiet and To conserve energy and lower limits
g/L) 2. verbalize at least 3 restful atmosphere tissue oxygen demands Vital signs taken as
HCT: 33% (39-54%) factors contributing to follows:
his condition 4. Provided safety by Weakness, fatigue and BP: 90/60 mmHg
Subjective: raising side rails restlessness are signs of HR: 100 bpm
Body weakness and 3. manifest at least 3 hypoxia which may cause Temp.: 37.0 C
dizziness as claimed interventions that injury to the patient RR: 21 cpm
would help with his
relieving symptoms 5. Administered Oxygen increase arterial 2. verbalized at least 3
supplemental oxygen saturation factors contributing to
as ordered his condition

6. Administered IV fluids Maintains circulating volume 3. manifest at least 3

as ordered to maximize tissue perfusion interventions that
would help with
7. Monitored laboratory Normal values indicate relieving his symptoms
studies such as adequate tissue perfusion
hemoglobin,
hematocrit and RBC

8. Blood component Blood transfusion increases

therapy (Blood the patient’s blood volume
transfusion) as and raising the hemoglobin
ordered level. Hemoglobin is a
 component of the red blood
cell that carries oxygen to
different tissues and organs
throughout the body.

9. Rendered health 9. Help client understand

teachings such as: that:
A. Avoid straining A. Straining for a bowel
movement further impairs
cardiac output and it
demands more oxygen.

B. Deep breathing B. Deep breathing exercises

exercises help in lung expansion.

C. Eat foods rich in iron C. to increase the capacity of

the RBC to carry oxygen
throughout the body.