PRIORITY PROBLEM #2: Impaired physical mobility related to limited strength as

evidenced by inability to move purposefully within physical environment,

including bed mobility, transfers, and ambulation secondary to chronic anemia

ASSESSMENT

Subjective Cues:

“Kami ang ga tabang saiya sir pag mag balhin sa wheelchair, mag adto sa cr ug
uban pa” as verbalized by patient’s significant other.

Objective Cues:

Restlessness

Limited Range-of-motion
Dependence on activities of daily living

GOALS AND OBJECTIVES

Short Term Goals:

After 8 hours of nursing interventions,

Long Term Goals:

After 3 days, the following goals should be met:
 Reestablish and maintain normal pattern of bowel functioning.

NURSING INTERVENTIONS AND RATIONALE

INDEPENDENT:
1. Assess ability to perform ROM to all joints.

R: This provides baseline measurement for future evaluation and guides therapy.
2. Keep side rails up and bed in low position.

R: this promotes a safe environment

3. Turn and position the patient every 2 hours or as needed.

R: Turning patients optimizes circulation to all tissues and relieves pressure

DEPENDENT:

1. Administer medications, as ordered.

R: To treat infectious process, decrease motility, and/or absorb water.

COLLABORATIVE:

1. Assist in treatment of underlying conditions and complications.

R: Therapies can include treatment of fever, pain, and infectious or toxic agents;
rehydration; and so forth.

EVALUATION

GOALS PARTIALLY MET, as supported by the following manifestations:

- Client’s response to treatment, teaching and actions performed

PRIORITY PROBLEM #3: Ineffective Peripheral Tissue Perfusion related to altered
affinity of hemoglobin for oxygen secondary to Chronic Anemia

ASSESSMENT

Subjective Cues:

“sakit akong dughan sir” as verbalize by the patient

Objective Cues:

Decreased hemoglobin concentration in blood

PR – 115 bpm
Restlessness
Hypoactive or absent bowel sounds

GOALS AND OBJECTIVE

Short Term Goals:

After 8 hours of nursing intervention, Patient engages in behaviors or actions to

Improve tissue perfusion.:

Long Term Goals:

After 2 days of nursing intervention, patient maintains optimal tissue perfusion to

vital organs, as evidenced by strong peripheral pulses, normal ABGs, alert level
of consciousness, and absence of chest pain.

INTERVENTIONS AND RATIONALE:

INDEPENDENT

1. Position Properly

R: This promotes optimal lung ventilation and perfusion.

2. Do passive range-of-motion exercises to unaffected extremity every 2 to 4 hours

R: Exercise prevents venous stasis and further circulatory compromise

DEPENDENT:

1. Administer oxygen as ordered.

R: Increasing arterial oxygen saturation delivers more oxygen to the myocardium

COLLABORATIVE:

1. Check the presence of elevated temperature and give paracetamol as prescribed.

R: Fever is one sign of infection and it need immediate interventions to prevent

worsening of the illness.

2. Refer the patient to the attending physician if there is worsening of the patient’s
health condition.

R: It signals presence of complications which needs immediate interventions.

EVALUATION

GOALS PARTIALLY MET, as supported by the following manifestations:

- Responses to interventions, teachings, and actions performed