ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Risk for falls Anemia is a condition in After 2 hours of nursing Establish rapport. Good rapport creates a close and After 2 hours of
“” as verbalized related to which the hemoglobin care, the patient will be harmonious relationship with nursing care, the
by the patient. postural concentration is lower than free of injury or risk for patients. It allows you to patient is free of
hypertension as normal. It reflects the fall understand your patient's feelings injury or risk for
Objective: evidenced by presence of fewer than the and communicate well with them. fall
BP- 120/80 fainting when normal number of
PR-70 standing and erythrocytes within the For patients at risk for Signs are vital for patients at risk
RR-20 dizziness circulation. The body falls, provide signs or secure a for falls. Healthcare providers
Temp- 36.4 stores of iron decreases as wristband identification to remind need to acknowledge who has the
•Dizziness do the stores of transferrin healthcare providers to implement condition for they are responsible
•Fainting when which binds and transports fall precaution behaviors. for implementing actions to
standing iron. This leads to promote patient safety and
•Weakness depletion of RBC, resulting prevent falls.
in decreased oxygen- Transfer the patient to a room
carrying capacity of the near the nurses’ station. Nearby location provides more
blood. constant observation and quick
response to call needs.
Move items used by the patient
within easy reach, such as call Items that are too far from the
light, urinal, water, and telephone. patient may cause hazard and can
contribute to falls.
Respond to call light as soon as
possible.
This is to prevent the patient from
going out of bed without any
Use side rails on beds, as needed. assistance.
For beds with split side rails,
leave at least one of the rails at According to research, a
the foot of the bed down. disoriented or confused patient is
less likely to fall when one of the
four rails is left down.
Guarantee appropriate room
lighting, especially during the
night.
See to it that the beds are at the
lowest possible position. If
needed, set the patient’s sleeping
surface as adjacent to the floor as
possible.
Patients, especially older adults,
has reduced visual capacity.
Lighting an unfamiliar
environment helps increase
visibility if the patient must get up
at night.
Keeping the beds closer to the
floor reduces the risk of falls and
serious injury. In some healthcare
settings, placing the mattress on
the floor significantly reduces fall
risk.
ASSESSMENT DIAGNOSIS INFERENCE
Subjective: Fatigue r/t Anemia is a condition in
“” as verbalized inadequate which the hemoglobin
by the patient. tissue concentration is lower than
oxygenation as normal. It reflects the
Objective: manifested by presence of fewer than the
inability to normal number of
maintain usual erythrocytes within the
level of circulation. The body
physical stores of iron decreases as
activity. do the stores of transferrin
which binds and transports
iron. This leads to
depletion of RBC, resulting
in decreased oxygen-
carrying capacity of the
blood.
PLANNING INTERVENTION
After 30 minutes of Establish rapport.
nursing intervention,
the client will be able to
verbalize reduction of
fatigue.
Assess the specific cause of
fatigue.
Assist the client in planning and
prioritizing activities of daily
living (ADL).
Assist the client in developing
a schedule for daily activity and
rest. Stress the importance of
frequent rest periods.
Educate energy-conservation
techniques.
RATIONALE EVALUATION
Good rapport creates a close and After 30 minutes of
harmonious relationship with nursing
patients. It allows you to intervention, the
understand your patient's feelings client verbalized
and communicate well with them. reduction of
fatigue, as
The specific cause of fatigue is evidenced by
due to tissue hypoxia from reports of increased
normocytic anemia; Other related energy and ability
medical problems can also to perform desired
compromise activity tolerance. activities. Goal
partially met.
This will allow the client to
maximize his/her time for
accomplishing important
activities. Not all self-care and
hygiene activities need to be
completed i the morning.
Likewise, not all housework
needs to be completed in one day.
Energy reserves may be depleted
unless the client respects the
body’s need for increased rest. A
plan that balances periods of
activity with periods of rest can
help the client complete desired
activities without adding levels to
fatigue.
Clients and caregivers may need
to learn skills for delegating task
 to others, setting priorities, and
clustering care to use available
energy to complete desired
activities. Organization and time
management can help the client
conserve energy and reduce
fatigue.

Provide supplemental oxygen Oxygen saturation should be kept

therapy, as needed. at 90% or greater.
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Deficient Anemia is a condition in After 30 minutes of Establish rapport. Good rapport creates a close and After 30 minutes of
“” as verbalized Knowledge r/t which the hemoglobin nursing intervention, harmonious relationship with nursing
by the patient. unfamiliarity concentration is lower than the client will be able to patients. It allows you to intervention, the
with the disease normal. It reflects the verbalize understanding understand your patient's feelings client verbalized
Objective: condition as presence of fewer than the of own disease and and communicate well with them. understanding of
evidenced by normal number of treatment plan. own disease and
questioning erythrocytes within the Explain the importance of the Diagnosing a type of anemia will treatment plan.
members of circulation. The body diagnostic procedures (such as be based on the changes in the
health care stores of iron decreases as complete blood count), RBC indexes
team and do the stores of transferrin
verbalization of which binds and transports Explain the hematological Clients usually have a basic
inaccurate iron. This leads to vocabulary and the functions of knowledge of the hematological
information depletion of RBC, resulting blood elements, such as white system.
in decreased oxygen- blood cells, red blood cells, and
carrying capacity of the platelets.
blood.
Instruct client to avoid known risk Causative factors such
factors. alcoholism, exposure to toxic
chemicals, dietary deficiencies,
and the use of some medications
can affect red blood cell
production and lead to anemia

Explain the importance of vitamin Vitamin B12 injections used to

B12 replacement. treat low levels (deficiency) of
this vitamin. They are given
monthly for the remainder of the
client’s life. It elevates levels of
vitamin B12, a deficiency caused
by a lack of intrinsic factor that
impairs the vitamin absorption.
Educate the client and the family
regarding food rich in iron, folic
acid, and vitamin B12.
The dosage and frequency of
administration will depend on the
severity of anemia. Iron
supplements are given orally with
meals to prevent gastric upset.
Intramuscular injections are also
available given via Z-track
method to prevent leakage of the
solution in the subcutaneous
tissue along the needle tract.
While folic acid is given
orally with a full glass of water.