NURSING CARE PLAN NO.

Date Identified : June 16, 2017

Cues Nursing Diagnosis Objectives/Evaluation Nursing Interventions Rationale Evaluation

Criteria
Objective cues: Fatigue r/t to Within 6 hours of 1. Determine possible causes of fatigue, such 1. Identifying the related factors with Goal met
"kadtung sa una, maayo decreased nursing interventions as: fatigue can benefit in recognizing After 6 hours of
pa akong lawas kay haemoglobin count the patient will be potential causes and building a nursing interventions
Last physical illness
mahimo pa nako akong secondary to anemia able to report collaborative plan of care. the patient was able
Pain
gusto pero karun improved sense of to improved sense of
Emotional stress
limitado na kaayo akong energy. 2. Fatigue can restrict the patients ability energy as evidenced
Depression
lihok tungod sa akong to participate in self-care and do his or by patient
Side effects of medication
kondisyuon, kapoy her role responsibilities in the family and verbalization " arang
Anemia
permi akong lawas" society, such as working outside the arang naman akong
Sleep disorders
home. paminaw "
- unable to interact well - Oxygenation
2. Assess the patients ability to perform
with the examiner due to 3. Decreased RBC indexes are associated 97 % with o2
ADLs, instrumental activities of daily living
weakness of muscle with decreased oxygen-carrying capacity
(IADLs), and demands of daily living (DDLs).
strength of the blood. It is critical to compare
- cannot tolerate serial laboratory values to evaluate
3. Monitor hemoglobin, hematocrit, RBC
maintain balance. (needs progression or deterioration in the client
counts, and reticulocyte counts.
assistance during and to identify changes before they
ambulation) become potentially life-threatening.
4. Assess the patients sleep patterns for
- capillary refill @ 3
quality, quantity, time taken to fall asleep and
seconds 4. Changes in the patients sleep pattern
feeling upon awakening and observe alteration
- weak as seen may be a contributing factor in the
in thought processes or behaviors.
- Speak in a slow, quiet development of fatigue. Numerous
and and hesitant manner. factors can exacerbate fatigue, together
Speak weakly 5. Identify energy conservation methods such with sleep deprivation, emotional
- drowsy as sitting and dividing ADLs into convenient distress, side effects of drugs, and
- dyspnoeic segments. Assist with movement or self-care progressing CNS disease.
- Hemoglobin : demands as appropriate.
71g/L (low) 5 Weakness can make ADLs almost not
- Erythrocytes: 6. Educate the patient and family about task possible for patient to finish. Being with
2.52 (low) organization methods and time organization the patient prevents the patient from
-Oxygenation methods. getting harm during activities.
94 % without o2
7. Anticipate the need for the transfusion of 6. Clients and caregivers may need to
packed RBCs. learn skills for delegating task to others,
setting priorities, and clustering care to
8. Aid the patient develop habits to promote use available energy to complete desired
effective rest/sleep patterns. activities. Organization and time
management can help the client conserve
9. Provide supplemental oxygen therapy, as energy and reduce fatigue.
needed.
7. Packed RBCs increase oxygen-
10. Administer ____________- carrying capacity of the blood.8.
Promoting relaxation before sleep and
providing for several hours of
uninterrupted sleep can contribute to
energy restoration.

9. Oxygen saturation should be kept at

90% or greater

10. Recombinant human erythropoietin, a

hematological growth factor, increases
hemoglobin and decreases the need for
RBC transfusions..