anemia april

7/27/2019 Anemia April

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APRIL MAY REYES

BSN 2

FOCUS: loss of appetite

NURSING CARE PLAN ANEMIA

ASSESSMENT SCIENTIFIC

BACKGROUND

DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

Hindi ako masyadong

makakain, wala akong

gana saka nanghihina

akoverbalizedby the

patient

Objective:

Observe evidenceof pain:

Protectivegestures

Positioning toavoid pain

Restless andirritable

Moaning Diaphoresis Change in muscle

tone ( flaccid)

Changes in vitalsigns

BP : 90/60mmhg PR: 60 bpm RR: 15 FHR: 110 bpm

Unpleasant sensory

motor and

emotional

experience arising

from potential or

actual tissue

damage or

described in terms

of such damage.

NOTE: pain is a

signal that

something is wrong

Acute pain

related to

deprivation of

oxygen and

nutrients

STO: after an hour shift

of rendering care, health

teaching, patient will be

relieved from pain and

demonstrate use of

relaxation skills and

diversional activities and

able to eat required

nutrients.

.

LTO: after 4 days of

continuous nursing

intervention the patient

will be able to maintain

normal ranges of vital

signs and no signs of

complications or distress.

Diagnostic:

Determine anddocument

presence of

possible

pathophysiological

and psychological

causes of pain

(e.g.sickle cell

anemia) Assess for

referred pain, as

appropriate.

Monitor vital signsespecially Fetal

heart rate.

Observe for verbaland non-verbal

cues and pain

behaviours.

Therapeutic:

To treat underlyingcondition.

Help determinepossibility of

underlying

condition or organ

dysfunction

requiring

treatment.

Baseline data todetermine signs of

fetal distress.

Observations maynot be congruent

with verbal reports

or may be only

indicator present

when client is

unstable to

verbalize.

STO:

Goal met.

patient was able

to relieve from

pain through

relaxation

techniques and

intervention

such as oxygen

therapy andDeep breathing

exercise

LTO:

Goal vital signs

are maintain to

each normal

ranges with no

signs of

complicationsand distress on

both sides


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Provide comfortmeasures.

Promote completebed rest.

Demonstrate deepbreathing

exercise.

AdministerOxygen

supplement if

indicated.

Educative:

Encourageadequate rest

periods.

Instruct andencourage use of

relaxation

techniques, such

as focused

breathing.

Discussimportance of

proper dietary

intake especially

during pregnancy.

Advise ironsupplement intake

with Vitamin C.

To promotepharmacological

pain management.

Prevent fetaldistress and

promote comfort.

Helps on relaxationand provide

oxygenation on the

fetus.

Prevent fetaldistress

To prevent fatigue

To distractattention and

reduce tension

Helps maintain abalance nutrition

on both mother

and baby

Enhanceabsorption of iron

and correct


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abnormalities in

RBC

anemia april

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