ASSESSMENT DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATIO

S N
SUBJECTIVE Ineffective Short - Monitor - To have a Short term:
“Nanghihina ako” tissue term: and record baseline -Goal
as verbalized perfusion After 3 Vital Signs data partially
related to hours of met. After 3
OBJECTIVE anemia nursing - Maintain - Restricte hours of
- Pallor interventio on bed rest d activity nursing
- Unable to n the reduces intervention
rise on patient oxygen the patient
bed will: demand was able to
- Poor skin do activities
turgor -Exhibits - Encourage - To but with
- Pale growing quiet and conserve minimal
palpebral tolerance restful energy assistance
conjuncti with environme and
va activity nt lower -Goal met.
- Low HGB tissue Patient was
level -Identifies oxygen able to
factors demand Identify
Vital signs that - Provide factors that
T- 36.5 improve safety by - Weaknes improve
PR- 80 bpm circulation raising the s can circulation
RR- 24 bpm side rails cause by
BP- 100/70 Longterm: injury to enumeratin
mmHg After 2 patient g 3 factors
days of - Monitor
nursing laboratory Longterm:
interventio studies - Normal -Goal met.
n the such as values After 2 days
patient will hemoglobi indicate of nursing
: n, adequate intervention
hematocrit tissue the patient
Maintain , and RBC perfusion was able to
maximum maintain
tissue - Administer maximum
perfusion blood tissue
transfusion - Source of perfusion as
iron that evidenced
the body by normal
- Provide can reuse vital signs
knowledge
on normal - Knowled
tissue ge of
perfusion causative
and factors
possible provides
causes of a
impairmen rationale
t for
treatmen
ts