NURSING CARE PLAN
ASSESSMENT DATA
Subjective:
“Bisan wala koy himuon,
bisan pa ug mag sigi ko
ug higda kapoy la
gihapon akong lawas,” as
verbalized.
Objective:
-Verbalization of
overwhelming lack of
energy even during rest
periods
-Inability to maintain
usual routines and ADLs
-Seen watcher assisting
client in performing
ADLs
-Hemoglobin level of 87
g/L (Normal: 120-150
g/L)
-Hematocrit level of 0.28
L/L (Normal: 0.37-0.47
L/L)
-RBC level of 3.22
x1012/L (Normal: 4.2-5.4
x1012/L)
- O2 saturation of 96%
- Respiratory rate of
26cpm
- skin and lips are pale in
color
DIAGNOSIS RATIONALE
Fatigue related to iron
Anemia is an important
deficiency anemia and
component of cancer-
anemia of colon cancer
related fatigue, which is
as evidenced by
one of the most common
verbalization of
and distressing
overwhelming lack of
manifestations
energy, inability to
experienced by the client.
maintain usual routines
In addition to fatigue,
and ADLs, low
anemic clients often
hemoglobin, hematocrit,
experience decreased
and RBC levels, oxygen
motivation and
saturation of 96% and
depression that interfere
respiratory rate of
with normal activities.
26cpm.
In mild cases of iron
deficiency anemia, the
client is asymptomatic; in
more severe cases,
assessment reveals the
general manifestations of
anemia including fatigue;
headache; dyspnea;
palpitations; pallor in the
face, palm of the hand,
nail bed, and mucous
membranes of the mouth
and conjunctiva; angular
stomatitis, glossitis, and
cheilitis; and brittle nails.
Source: Medical-Surgical
Nursing: Clinical
Management for Positive
outcomes by Joyce M.
Black and Jane Hokanson
Hawks, 8th edition, page
291-292, & 2018
PLANNING INTERVENTIONS
Short-term goal: Independent:
After 5 days of nursing 1. Evaluated client`s
interventions, client will response to activity. Note
report improved sense reports of dyspnea,
of energy. increased weakness,
fatigue, and changes in
vital signs during and after
Long-term goal: activities.
After 1-2 weeks of
nursing interventions, 2. Planned care to allow
client will be able to for rest periods. Scheduled
perform ADLs and activities for periods when
participate in desired patient has most energy.
activities at level of Involved client and
watcher in schedule
ability.
planning.
3. Established realistic
activity goals with client.
4. Explained importance
of rest in treatment plan
and necessity for
balancing activities with
rest.
5. Assisted to assume
comfortable position for
rest and sleep.
6. Encouraged watcher to
stay at bedside always.
RATIONALE EVALUATION
Partially met
Post-blood
1. This establishes client`s transfusion client’s
capabilities and needs, and feeling of fatigue is
facilitates choice of relieved. Client has
interventions. improved sense of
energy and is able to
accomplish some
ADLs such as eating
alone and walking.
2. Frequent rest periods and Days post-blood
naps are needed to restore and transfusion client
conserve energy. Planning also starts to feel
will allow client to be active fatigued again.
during times when energy
level is higher, which may
restore a feeling of well-being
and a sense of control.
3. Weakness may make ADLs
difficult to complete or place
the client at risk for injury
during activities.
4. To decrease metabolic
demands, thus conserving
energy.
5. To promote rest.
6. To assist patient’s needs
and to secure safety.
7. Assisted with self-care
activities as necessary
such as ambulation, sitting
up in chair, bathing, etc.
8. Encouraged to consume
foods rich in iron such as
beans, egg yolk, kidney,
liver, and oatmeal.
9. Ascertained client`s
ability to stand and move
about and degree of
assistance needed or use
of equipment.
Dependent:
10. Provided supplemental
oxygen as ordered.
11. Administered iron
supplements as ordered:
a. Ferrous sulphate 1 tab
OD
b. Ferrous fumirate 1 tab
BID
12. Transfused 1 unit of
PRBC as ordered by the
physician.
7. Minimizes exhaustion and
helps reduce oxygen demand.
8. To aid in increasing iron
levels in the body.
9. To sustain motivation of
client.
10. To promote balance
between oxygen supply and
demand.
a. Elevates the serum iron
concentration, and is then
converted to Hgb or trapped
in the reticuloendothelial cells
for storage and eventual
conversion to a usable form of
iron.
b. Provides elemental iron, an
essential component in the
formation of hemoglobin.
12. To correct anemia
immediately.