ASSESSMENT NURSING SCIENTIFIC NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLANATION GOAL INTERVENTION

SUBJECTIVE: Activity Dec. oxygen Short Term: Independent Mgt: Short Term:
intolerance carrying capacity
“Agkakapsuttak r/t of Hgb After 8 hours  Assess  Influences After 8 hours of
ken, marigatanak Muscle of nursing patients ability choice of nursing intervention,
aggunay”as weakness intervention, to perform interventions or GOAL was met, as
verbalized by the 2o to the patient ADLs noting needed evidence by:
pt. Decreased will: reports of assistance
hemoglobin Decreased nutrition weakness, a. Patient’s back
OBJECTIVE: level. in cells a. Be free fatigue and and buttocks are
from difficulty in free from
 Weak in decubitus accomplishing bedsores/hemato
appearanc ulcer/bedso task mas respectively
e res or  Promote  Mild/moderate and free from
 With Pale hematomas independence activities & swelling/redness
Decreased ATP on the as well.
skin and in self-care improved self-
production since most
conjunctiv activities as esteem are
oxygen is needed prominent
a tolerated promoted.
for oxidation of parts of the Long Term:
 With CHO/glucose  Encourage  Minimized
fatigabilit body such alternating exhaustion &
y as the back activity with helps balance Within 2 days of
 Looks and the rest O2 supply and nursing
thin in buttocks. demand. interventions,
appearanc  Explain GOAL was partially
 Bedrest is
e Long Term: importance of met, as evidence by:
Decreased energy maintained to
 Dec. Hgb. or muscle be rest in decrease
Level; Within 2 days treatment. a. The patient
weakness metabolic
12.9 g/dl of nursing Verbalized
demands thus
interventions, partial
conserving
the patient dependence on
energy.
will:  Monitor ADLs with his
 To identify the S/O such as able
laboratory extent of
Activity a. Be results like to feed himself,
completely deficiency & assistance in
intolerance Hgb. & Hct. for better
independent treatment plan. toileting &
on all ADLs  To increase iron bathing.
and without  Encourage supplement of b. Demonstrates
asking increase intake the body. Improved skin
assisitance of iron-rich turgor & well being
with his S/O foods. c. Able to
b. Have good participate in self
skin turgor care activities
c. Have (grooming dressing)
normal d. Hgb and Hct
hemoglobin level still needs to
level from 104 be evaluated.
g/L to 120g/L
Hct. from 31%
to 40%.
d. Reports
increased
sense of well
being