NAME:
ASSESSMENT EXPLANATION OF
THE PROBLEM
Subjective: The patient was
hospitalized to receive
"I feel weak and I easily chemotherapy treatment for
get tired. I think I don't endometrial adenoma
have energy".
carcinoma.
Chemotherapeutic agents
Objective:
are notorious for
 With pallor and suppressing the bone
pale conjunctiva marrow, this results in the
 Needs assistance patient having low
with activities of hemoglobin and hematocrit
daily living levels respectively, leading
 Exertional to her having anemia.
discomfort Anemia is the most
(RR=22 cpm) common hematologic
 Low hemoglobin disorder in which the
level - 88g/L hemoglobin level is lower
 Low hematocrit than normal, reflecting the
level - 0.26L/L presence of a decrease in
the number or derangement
in the function of red blood
cells within the circulation.
As a result, the amount of
Nursing Diagnosis:
oxygen delivered to body
FATIGUE related to tissues is also lessened,
decreased hemoglobin leading to a feeling of
level and diminished reduced level of energy,
oxygen-carrying increased respiratory rate
with little work and
capacity of the blood
OBJECTIVES NURSING INTERVENTIONS
STO:
Within 30 minutes-1 hour
of effective nursing
interventions, the patient
will be able to:
a) identify basis of fatigue
and individual areas of
control.
b) verbalize understanding
of the use of energy
conservation principles.
c) participate in
recommended treatment
program.
LTO:
Within 24-48 hours of
effective nursing
interventions, the patient
will:
a) report improved sense of
DATE: _____________
Dx:
 Identified presence of
physiological condition (s) e.g.
anemia.
 Assessed ability to perform
activities of daily living.
 Measured physiological
response to activity .e.g. changes
in respiratory rate.
 Reviewed laboratory results of
blood profile particularly red
blood cells indexes.
Tx:
 Accepted reality of patient’s
reports of fatigue and effect on
patient’s quality of life.
 Assisted with activities of daily
living and promoted comfort
and rest.
 Promoted safety by constant
RATIONALE
 To assess the specific cause
of fatigue this is mostly due
to tissue hypoxia from
normocytic anemia.
 Fatigue can limit the patient's
ability to participate in self-
care.
 To determine degree of
fatigue and impact on life.
 Decreased RBC indexes are
associated with decreased
oxygen-carrying capacity of
the blood.
 Report of fatigue is
subjective and only the
patient can explain it.
 To help conserve energy and
assist in coping with fatigue.
 Because of inability to
maintain usual level of
physical activities, safety
EVALUATION
STO:
(Goal Met)
Within 30 minutes-
1 hour of effective
nursing
interventions, the
patient identified
the basis of fatigue,
how she can control
it, verbalized
understanding of
the use of energy
conservation
principles and took
the prescribed
medications
accordingly.
LTO:
(Goal Met)
Within 24-48 hours
of effective nursing
interventions, the
patient reported
secondary to anemia as inability to perform
manifested by a activities of daily living;
decreased sense of collectively known as,
energy and capacity for FATIGUE, which is
physical work. defined as an
overwhelming sustained
sense of exhaustion and
decreased capacity for
physical and mental work
at usual level (NANDA).
SOURCE/S:
McCance, K.L. & Huether,
S.E. (2017). Understanding
Pathophysiology: The
Biologic Basis for Disease
in Adults and Children (6th
ed.). St. Louis:
Elsevier/Mosby.
Potter, P.A., Perry, A.G.,
Stockert, P.A., & Hall,
A.M. (2018). Essentials for
Nursing Practice (9th ed.).
St. Louis: Elsevier.
Potter, P.A., Perry, A.G.,
Stockert, P.A., & Hall,
A.M. (2017). Fundamentals
of Nursing (9th ed.). St.
Louis: Elsevier/Mosby.
energy
b) perform ADLs and
participate in desired
activities at level of ability.
monitoring, keeping bed in low
position and travel ways clear of
furniture.
 Ensured the patient took the
prescribed medication of
FeSO4+Folic acid with water or
orange juice and not milk.
 Administered and regulated the
packed red blood cells flow rate
as ordered.
Edx:
 Educated on energy-
conservation techniques such as
delegating tasks to others,
having frequent rest periods and
doing deep breathing exercise
when exhausted.
 Encouraged to increase the
consumption of foods high in
dietary iron such as malunggay,
spinach and liver. And also the
intake of foods high in folic acid
and vitamin B12 such as green
leafy vegetables and dairy
products.
 Instructed patient in ways to
monitor responses to activity
and significant signs/symptoms
that may indicate the need to
may be compromised. improved sense of
energy was seeing
walking unassisted
 To promote absorption of
to the comfort room
iron as milk decreases
and was able to
absorption.
perform activities
of daily living by
herself.
 Packed red blood cells
increase oxygen-carrying
capacity of the blood thereby
reducing fatigue.
 All these measures can help
the patient conserve energy
and reduce fatigue.
 To stimulate red blood cells
production in the bone
marrow thereby improving
the hemoglobin level and
facilitating optimum
recovery from anemia.
 To prevent accidents and
promote wellness.
 www.nurseslab.com alter activity level.

 Advised to report promptly any

untoward feelings and concerns.  To ensure timely intervention
and prevent complications.

ASSESSMENT:
1. Focus on your Nursing Diagnosis (Subjective and Objective cues should ALL be align with your problem)
2. Subjective data (preferably verbalization from the patient and must be in an open and close quotation otherwise if it is coming from the mother or any significant other, it must
be categorize as subjective data from a secondary source or an objective data [if it can be perceived by the senses, verified by another person observing the same patient, and
tested against accepted standards or norms] from a secondary source).
3. Objective data (start with the most obvious observation that is related to your nursing diagnosis to the less obvious, followed by abnormal vital signs that are related to your
problem and any laboratory results that are relevant to your problem)
4. For Nursing Diagnosis, use the 3-Part Statement: PES Format (Problem + Etiology + Signs and Symptoms) Three parts are joined together by “related to” or “associated
with” and “as manifested by” or “as evidenced by”
EXPLANATION OF THE PROBLEM:
1. Should be in paragraph form, it’s just like doing your pathophysiology but explaining in detail how the problem arise in relation to your objective data and other signs and
symptoms manifested by the patient that are related to your problem.
2. DO NOT FORGET to indicate your source as a basis in coming up with your explanation of the problem.
OBJECTIVES:
1. Must follow the concept of SMART (Specific, Measurable, Attainable, Realistic and Time bound).
2. STO (Short Term Goal). In theory it covers your acute care (till 6 months). But for our requirement we measure our STO within the shift (0 – 8 hours). A better parameter
would be using ranges of time depending on the planned activities.
3. LTO (Long Term Goal). In theory it covers your chronic care (6 months and above). But for our requirement we measure our LTO within the first day to the third day or one
rotation (24 – 72 hours). A better parameter would be using ranges of time depending on the planned activities.
NURSING INTERVENTION:
1. Dx (diagnostics) should be based on your SUBJECTIVE and OBJECTIVE DATA.
2. Tx (therapeutics) should be arrange as ICDS (Independent nursing function, Collaborative [other health-care professional aside from the physician], Dependent nursing
function [physician/doctor], Supportive [Significant others, clergy/priest, and non-health care professional]
3. Edx (educative) should be based on the most needed by the patient that is relevant to the nursing diagnosis. (you can also base it on your STO and LTO if there are educative
goal)
RATIONALE:
1. It must be aligned with your nursing intervention and relevant to the case of you patient.
2. For the administration of medication, your rationale should be the indication of the drug in relation with the patient’s case.
EVALUATION/ EXPECTED OUTCOMES:
 1. Evaluation for ACTUAL PROBLEM and your NURSING INTERVENTION should be past tense.
2. EXPECTED OUTCOME for POTENTIAL PROBLEM and your NURSING INTERVENTION should be future tense.
3. Should evaluate (GOAL MET, GOAL NOT MET or GOAL PARTIALLY MET) accurately and should be supported by results from your STO and LTO.
4. For expected outcomes (GOAL MET IF, GOAL NOT MET IF or GOAL PARTIALLY MET IF), and give parameters for the IF.
5. Should discuss or make recommendation/s for goal not met and partially met.

Always remember that NURSING PROCESS is SYSTEMATIC, PATIENT-CENTERED, GOAL-ORIENTED AND DYNAMIC.