NURSING CARE

WITH ANEMIA CASE

Arranged by :
RETVIKA VALLENTINA SAPUTRI

1911020162

NURSING STUDY PROGRAM SI

FACULTY OF NURSING SCIENCES
MUHAMMADIYAH UNIVERSITY PURWOKERTO
YEAR 2019
 DATA ANALYSIS

FOCUS DATA PROBLEM ETIOLOGY DIAGNOSIS

DS : Ineffective Decreased Ineffective
tissue hemoglobin peripheral tissue
- Mr. S complained of feeling
perfusion concentration perfusion related
dizzy,
to decreased
- The patient says he feels weak hemoglobin
concentration
- The patient said that he felt
tired in carrying out his
activities
DO:
- The patient looks pale
- The conjunctiva appears
anemic
- Pale lips
- The patient looks weak
- HB <8
- TTV : TD : TD 186/120
- N : 121x/minute
- SB 38.1
- RR 20
- SpO2 98%
DS: Hyperthermia DD disease Hyperthermia bd
- The patient said the fever (D.0130) process with disease process
never got better, only warm axles and
fluctuated increased body
- The patient says he has a temperature
fever, especially at night (D.0130)
- The patient said that he often
had a fever before being taken
to the hospital
- The patient says he shivers
every time he has a fever
DO:
- The patient's acral feels warm
- The patient is seen shivering
with fever
- S: 38.1 C
NURSING DIAGNOSES

a. Ineffective peripheral tissue perfusion related to decreased hemoglobin

concentration.

b. Hyperthermia related to the disease process

ACTION PLAN
No. Nursing Objectives and Outcome Criteria Intervention (SIKI) Rational Name/T
diagnoses (SLKI) TD
1. Ineffective After care Circulation treatment Retvika
• To determine peripheral
peripheral nursing 2 x 24 hours it is expected
circulation
tissue that peripheral perfusion will O:
perfusion increase (L.02011) with the • Know the factors that cause
• Check peripheral circulation (eg
related to following criteria: disturbances in circulation
peripheral pulse, edema, capillary
decreased Peripheral perfusion (L.02011)
hemoglobin Indicator A Q
filling, color, temperature, ankle • To avoid a decrease in the
brachial index) elasticity of blood vessels
concentration. Peripheral pulse 2 5
Capillary filling 2 5 • Identification of risk factors for
Acral 2 5 circulation disorders (eg diabetes,
Skin turgor 2 5 smoking, elderly, hypertension and
high cholesterol levels)
Information :
1. Worse Q:
Decrease
• Take infection prevention
2. It just got worse
3. Currently • Do foot and nail care
4. Just getting better
5. getting better • Hydrate

E:
• Suggest regular exercise
• Suggest taking blood pressure control
medication regularly
• Advise a dietary program to improve
 circulation (eg low in saturated fat,
fish oil, omega3)
• Inform emergency signs and
symptoms that should be reported (eg
pain that does not go away at rest,
wound that does not heal, loss of
feeling)

K:
• Drug delivery collaboration
2. Hyperthermia After nursing actions for 2x24 hours Management of Hyperthermia (I.15506) Retvika
• To find out the cause of
related to the it is hoped that thermoregulation will O:
fever
disease improve with the following criteria: • Identify the cause of the fever
process • Monitor body temperature • To determine changes in the
Thermoregulation (L.14134) • Monitor complications due to patient's body temperature
Indicator A Q hyperthermia
• To lower the patient's body
Q:
Body 2 5 temperature
• Give a warm compress
temperatur
• Give oral fluids • To provide comfort to the
e
patient
Pale 2 5
Shivering 2 5
E:
Information • Suggest bed rest
1. Deteriorating K:
2. Moderately deteriorated Collaboration giving paracetamol infusion 1
3. Medium gram
4. Moderately improved
5. Improved
IMPLEMENTATION

Day No. Implementation Evaluation Name/T

Diagnosis TD
1. at 1 Retvika
• Check peripheral circulation (eg peripheral pulse, S :
09.00
edema, capillary refill, color, temperature, ankle
pm - The patient said his body was still weak
brachial index)
- The patient says that he doesn't have the
• Identify risk factors for circulation disorders (eg
energy
diabetes, smoking, elderly, hypertension and high
cholesterol levels) - The patient says he still feels dizzy
O:
• Monitor for heat, redness, pain, or swelling of the
extremities - The patient looks pale
- The patient looks weak
• Do infection prevention
- The patient has received his 5th colf blood
• Perform foot and nail care transfusion
• Suggest regular exercise - HB :<8
• and emergency symptoms to report (eg pain that - Temperature : 38.1˚C
does not go away at rest, wound that does not heal, - BP : 186/120 mm Hg
loss of feeling)
- N 121 x/minute
• Collaborating medication administration
- Palms and feet look pale
A : the problem of tissue perfusion has not been
resolved

Indicator A H Q

Peripheral pulse * 2 2 5
Capillary filling 2 2 5
Acral 2 2 5
Skin turgor 2 2 5

Q: continue the intervention

- Check peripheral circulation (eg
peripheral pulse, edema, capillary refill,
color, temperature, ankle brachial index)
- Identify risk factors for circulation
disorders (eg diabetes, smoking, elderly,
hypertension and high cholesterol levels)
- Monitor for heat, redness, pain, or
swelling of the extremities
- Do infection prevention
- Perform foot and nail care
- Suggest regular exercise
- and emergency symptoms to report (eg
pain that does not go away at rest, wound
that does not heal, loss of feeling)
1 at 2 • Identify the cause of the fever S:
09.30 • Monitor body temperature - The patient says that his body has a fever
pm • Monitor complications due to hyperthermia in the late afternoon, and in the morning
• Give warm compresses - The patient says he doesn't drink much
• Give oral fluids water, more or less 5 glasses a day
• Advise for bed rest - Patients say that after compressing it feels
more comfortable
• Collaborating in the administration of paracetamol O:
infusion of 1 gram - The patient just lies down
- Pale lips
- Temperature 38.1
- The patient received paracetamol therapy
inf 1 gram
A: The problem of thermoregulation nursing has
not been resolved

Indicator A S Q
Body 2 2 5
temperatur
e
Pale 2 2 5
Shivering 2 2 5
Q: Continue the hyperthermia management
intervention
• Identify the cause of the fever
• Monitor body temperature
• Monitor complications due to
hyperthermia
 • Give warm compresses
• Give oral fluids
• Advise for bed rest
• Collaborating in the administration of
paracetamol infusion of 1 gram
2. at 1 S: Retvika
• Check peripheral circulation (eg peripheral pulse,
10.00
edema, capillary refill, color, temperature, ankle - The patient said that he was no longer
pm
brachial index) weak, dizzy and his body felt better
O:
• Identify risk factors for circulation disorders (eg
diabetes, smoking, elderly, hypertension and high - The patient looks fresher than before
cholesterol levels) - HB 11.9
• Monitor for heat, redness, pain, or swelling of the - Temperature : 37.5˚C
extremities
- BP : 150/100 mm Hg
• Do infection prevention
- N 100x/minute
• Perform foot and nail care
- The acral is hot
• Suggest regular exercise
- The patient is no longer pale
• and emergency symptoms to report (eg pain that A : the network perfusion problem is resolved
does not go away at rest, wound that does not heal, Indicator A H Q
loss of feeling)
Peripheral pulse * 2 4 5
• Collaborating medication administration
Capillary filling 2 4 5
Acral 2 4 5
Skin turgor 2 4 5

Q: Stop the intervention

2. . at 2 • Identify the cause of the fever S: Retvika
10.30 • Monitor body temperature - The patient said that today he has no fever
pm • Monitor complications due to hyperthermia - Have been drinking lots of water
• Give warm compresses - The patient said that he was not shivering
• Give oral fluids too much
• Advise for bed rest O:
- The patient is able to move
• Collaborating in the administration of paracetamol - Moist lip mucosa
infusion of 1 gram - Temperature 37.0C
A: Problem is partially resolved
Indicator A S Q
Body 2 4 5
temperatur
e
Pale 2 4 5
Shivering 2 4 5
Q: Stop hyperthermia management interventions