NURSING CARE PLANS

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Activity Intolerance Within our 2-day Independent: Within our 2-day
related to imbalance holistic nursing care, holistic nursing care,
SO verbalized: between oxygen the client will be - Monitor vital and -To serve as the the client can be able
supply and demand able to increased cognitive signs, baseline data and to
to increased condition
- “ga luya mani sya condition of physical watching for changes know the patient’s
state as evidenced overall health status. of physical state as
ug gihilantan, ga ubo in blood pressure,
pud ug ga luspad, by: heart, and respiratory evidenced by:
iyang hemoglobin kay rates; note skin pallor
mubo pud” -Vital signs and and/ or cyanosis and
hemoglobin level presence of confusion -Partially met.
within normal range Vital signs and
- “probably naa ni sya
T: 36.5-37.5 hemoglobin:
ani nga sakit kay naa - Determine the - To provide a baseline
PR: 75-110 bpm T: 36.4
pud koy minor patient’s level of for comparison and
RR: 20-30 cpm PR: 100 bpm
thalassemia nga na activity intolerance track patient’s progress
SpO2: 95-100% RR: 28 cpm
discover ra pud atong
sukad pag diagnose sa BP: Systolic 97- - Increase exercise/ SpO2: 99%
-To provide information
iya.” 112, diastolic 57- activity levels about the impact of
BP: 100/80
71 gradually; teach activities on fatigue and Hmg: 8.90 g/dl
- “among pamilya kay Hmg: 12-14 g/dl methods to conserve energy reserves.
permi pud naga energy -Met. Patient
experience ug -To promote rest and verbalized she can
kakuyapan niya wala -Encourage use of comfort. ambulate to comfort
- Report measurable
ra gipa check-up.” relaxation techniques. room independently.
increase in activity
tolerance and use -Met. Patient uses
- “sa wala pa siya ma- identified techniques Dependent:
admit mag bike ra na minimal effort in doing
to enhance activity activities.
siya pero karon dili intolerance Administer
na.” medications as
- Demonstrate ordered: - To increase the
methods of O2 therapy at 2-3 amount of oxygen
techniques to L/min carried by available
 jjy

Objective: conserve energy. hemoglobin in the

blood.
Vital Signs: Furosemide 20 mg -To reduce the vascular
T: 36.5 IVTT post BT overload that may be
RR: 19cpm imposed by the
hhfuu

PR: 99 bpm additional blood

BP: 80/60mmHg volume delivered
O2 Sat: 109% during transfusion.
Hemoglobin level: Cefuroxime 750 mg - Use to treat a certain
4 g/dl IVTT q12h (ANST) infection caused by
-Facial Grimace is bacteria.
noted Collaborative:
-Weak in appearance
-Limited range in - Ask for assistance
motion from a healthcare -To help prevent
-Pale gingiva and provider if needed in worsening health issues
conjunctiva performing activities and injuries and to
-Restless of daily living. ensure care.
-Hemoglobin Level:
4.0

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Fatigue related to Within our 2-day Independent:
decreased holistic nursing care, Within our 2-day
SO verbalized: hemoglobin level the client will be free - Monitor vital signs. -To serve as the holistic nursing care,
from fatigue as baseline data. the client is free from
- “ga luya mani sya evidenced by: fatigue as evidenced
ug gihilantan, ga ubo - Monitor CBC - To help find the cause by:
pud ug ga luspad, - Normal range of: of symptoms such as
iyang hemoglobin kay Hemoglobin level: weakness, and fatigue. -Partially met.
mubo pud” 12-14 g/dl Hemoglobin level:
-To help ensure if the 8.90 g/dl
- “probably naa ni sya - Demonstrates -Assess the client’s patient needs assistance
ani nga sakit kay naa absence of fatigue ability to perform to accomplish activities -Partially met.
pud koy minor and weakness. activities of daily of daily living. Patient least interacts
thalassemia nga na living. with people
discover ra pud atong - Perform activities - To establish specific surrounding her.
sukad pag diagnose sa of daily living and treatment
iya.” participate in desired - Assess the extent of -Met. Patient can
activities at level of fatigue in daily life. ambulate without
- “among pamilya kay ability
assistance.
permi pud naga
experience ug - Reports of Dependent: - To increase the
kakuyapan” improved ability to amount of oxygen
do activities in daily - Administer O2 carried by available
life. Therapy as prescribed hemoglobin in the
blood.
Objective:
- To ensure that the
-Facial Grimace is patient receives
noted - Administer IV appropriate and timely
-Weak in appearance medication like treatment.
-Limited range in Cefuroxime and
motion Furosemide
-Pale gingiva and
conjunctiva
-Restlessness
-Hemoglobin Level:
4.0
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Chronic pain related Within our 2-day Independent: Within our 2-day
to enlargement of holistic nursing care, holistic nursing care,
-Patient verbalized abdomen the client will be free -Obtain client’s -To rule out worsening the client is free from
“Mo sakit akong from pain as assessment of pain to of underlying fatigue as evidenced
tiyan basta evidenced by: include location, condition/development by:
matandog” characteristics, of complications.
Report pain is onset/duration,
-Significant others relieved/controlled frequency, quality,
verbalized “Iyang intensity, and
tiyan is mo dako Demonstrate use of precipitating/aggravating
kung kulang siya og relaxation skills and factors.
dugo pero kung diversional activities,
maabunohan na as indicated, for -Use pain rating scale -Helps to keep track of
mawala ra pd” individual situation. appropriate for how well the treatment
age/cognition. plan is working to
-Rate pain as 6/10 reduce pain
(whereas 10 is most
painful and 1 as least -Provide comfort To promote
painful) measures, quiet nonpharmacological
environment, and calm pain management
Objective: activities
- Facial Grimace is The human body is
noted -Encourage relatives to believed to have
- Limited range in perform touch therapy energy fields that
motion express aberrant
- Abdominal patterns when body
guarding systems are insulted.
- Enlargement of the Therapeutic touch is
left upper quadrant thought to realign
upon palpation aberrant fields
 Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective: Risk for infection Within our 2-day Independent: Within our 2-day
Significant other related to decrease holistic nursing holistic nursing
verbalized hemoglobin care, the client will Provide clean ventilated To reduce spread of care, the client is
“Ga luya mani sya be able to prevent environment microorganisms able to prevent
ug gihilantan, ga infection evidenced infection evidenced
ubo pud ug ga by: Emphasize proper use of For particular by:
luspad, iyang personal protective exposure risk
hemoglobin kay Hemoglobin level equipment by staff and Partially Met.
mubo pud” within normal range visitors, as indicated by Patients
- “Among pamilya Hgb 12-16 g/dl agency policy Hemoglobin level
kay permi pud naga is 8.90L
experience ug Identify intervention Monitor and report any
kakuyapan” to prevent or reduce signs and symptoms of Met. Significant
risk of infection infection other verbalized
“sig era ko pakaon
Objective: Demonstrate Signs and symptoms
niya ug utan’’
techniques and Monitor white blood cell of infection vary
-Weak in lifestyle changes to count according to the body
Met. Patient’s
appearance promote safe area involve
environment is well
-Pale gingiva and environment clean and ventilated
conjunctiva An increasing white
-Restlessness blood cell count
-Hemoglobin indicates the body’s
Level: 4.0 Encourage intake of efforts to combat
protein-rich and calorie- pathogens
rich foods and
encourage a balanced Proper nutrition and a
diet balanced diet support
the immune systems’
responsiveness and
enhance the health of
all body’s tissues.
Adequate nutrition
enables body to
maintain rebuild
tissues and helps keep
the immune system
function well