ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Irritability Impaired Gas General: Independent: After the whole stay

Pallor on face and Exchange related to - To facilitate the of the patient in the
fingers on both low RBC count as maintenance of oxygen to Assess patient’s respirations: Rate, This will serve as indicators of respiratory ICU, patient was able
extremities evidenced by pallor all body cells rhythm, depth and and breathing effort function and assess the therapy needed by the to achieved:
V/S: on the face and patient
T – 36.5 ºC fingers, and After 1 day of effective Increase
P – 129 bpm dyspnea nursing interventions the Monitor vital signs, note for changes in Hypoxia is associated with signs of increased hemoglobin level
R – 58 patient will be able to: cardiac rhythm breathing effort after blood
breaths/min transfusion
1. Display laboratory
Lab tests: values within acceptable Recommend quiet atmosphere and bed This enhances rest to lower body’s oxygen Return of pinkish
Hb – 68 gm/L range rest if indicated requirements and reduces strain on the heart and color on both hands
HCT – 0.23% lungs and face
RBC – 2.91 x 1012/L 2. Manifest glow on the .
face and return of color on
the fingers
Recommend mother to stimulate the baby Enhances lung expansion to maximize
to cry once in a while oxygenation for cellular uptake.

Collaborative:
Monitor Hb levels Low Hb levels reduce the uptake of oxygen at
the alveolar capillary membrane and oxygen
delivery to tissues

Administer packed RBCs or exchange This increases number of oxygen-carrying cells,

transfusions as indicated improve circulation. PRBCs are used because
they are less likely to create circulatory overload

Administer meds as indicated: Drug therapy helps to increase haemoglobin

- Ferlin i ml BID levels and promote maximum potential of
-Folic Acid 5 mg i tab BID wellness
-Fortum 270 mg IV q2H NST