Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

Subjective: Fatigue related to Fatigue occurs After 8 hour of -Assess the specific -The specific cause After 8 hour of
decreased because there’s nursing intervention cause of fatigue. of fatigue is due to nursing
hemoglobin and inadequate oxygen the patient will able tissue hypoxia from intervention, the
diminished oxygen- levels in the tissues to: normocytic anemia; goals were partially
carrying capacity of that should have  Verbalize use Other related met; the patient
Objective: the blood. been carried by of energy medical problems verbalized the use
Tired hemoglobin. conservation can also of energy
compromise
Reports of lack of principles. conservation
activity tolerance.
energy  Verbalize principles. And
Tiring easily -Assess the client’s -Fatigue can limit
verbalized the
reduction of reduction of
ability to perform the client’s ability
fatigue, as fatigue, as
activities of daily to participate in
evidenced by
evidenced by living (ADLs), and self-care and
reports of increased
reports of the demands of perform his or her
energy and ability
daily living. role responsibilities
increased to perform desired
in family and
activities.
energy and society, such as
working outside the
ability to
home.
perform
desired -Monitor - Decreased RBC
hemoglobin, indexes are
activities. associated with
hematocrit, RBC
counts, and decreased oxygen-
reticulocyte counts. carrying capacity of
the blood. It is
critical to compare
serial laboratory
values to evaluate
progression or
deterioration in the
client and to
identify changes
 before they become
potentially life-
threatening.

-Assist the client in -This will allow the

planning and client to maximize
prioritizing his/her time for
accomplishing
activities of daily
important activities.
living (ADL).
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
Assessment Diagnosis Inference Planning Intervention Rationale Evaluation
Objective: Risk of bleeding: At Platelets play an After 8 hour of -Assess the skin for -Bruises and
Petechial rashes risk for a decrease important role in intervention client bruises and petechiae is usually
Ecchymoses in blood volume clotting and will have a reduced petechiae. evident when the
and platelet count bleeding. In people risk for bleeding, as platelet count
that may with low platelet evidenced by drops to 20,000
compromise health count, bleeding is normal or adequate mm3.
as evidenced by more likely to platelet levels and
Bone marrow occur, even after absence of bruises - Assess for any - Early assessment
malfunction. slight injury. Low and petechiae. frank bleeding from facilitates
platelet count may the nose, gums, immediate
result in vagina, or urinary or treatment. These
spontaneous gastrointestinal sites are most
bleeding tract. common for
spontaneous
bleeding
-Monitor platelet
-A low platelet
count.
count or
thrombocytopenia
is caused by a bone
marrow
malfunction
resulting from
nutritional
deficiencies, drugs,
certain viral causes,
or aplastic anemia.
The risk for
bleeding is
increased as
platelet count is
decreased.
- Anticipate the - Platelet
need for a platelet replacement may
transfusion once be required to
the platelet count reduce the risk of
drops to a very low bleeding.
value Premedication with
antihistamine and
antipyretics reduce
transfusion reaction
side effects.
Assessment Diagnosis Inference planning Intervention Rationale Evaluation
Risk of infection: at After 8 hours of -Assess for local or -Opportunistic After 8 hours of
increased risk for nursing systemic signs of infections can easily nursing
being invaded by intervention the infection, such as develop, especially intervention the
pathogenic client will reduce fever, chills, in immune goal was met; the
organisms as the risk of infection; swelling, pain, and compromised client reduced the
evidenced by bone and implement the body malaise. clients. risk of infection as
marrow preventive evidenced by an
malfunction. measures such as - Monitor WBC - A low white blood absence of fever
proper hand count. cell count normal white blood
washing. (leukopenia) is a cell count, and
decrease in disease- implementation of
fighting cells preventive
(leukocytes) in your measures such as
blood. In general, proper hand
for adults a count washing.
lower than 4,000
white blood cells
per microliter of
blood is considered
a low white blood
cell count.

- Instruct the client - A simple fever is

to report signs and significant enough
symptoms of not to pay attention
infection to. A need for
immediately. antibiotic therapy
may be indicated.

- Anticipate the - These agents are

need for antibiotic, effective against
antiviral, and killing an infection.
antifungal therapy.

- Teach the client - Practicing hand

and visitors the hygiene is an
proper hand effective way to
washing. prevent infections.
Washing hands can
prevent the spread
of germs, including
those that are
resistant to
antibiotics.
Assessment Diagnosis Inference Planning intervention rationale evaluation
Activity A patient who has After 8 hours of -Assess for signs of -Dyspnea on After 8 hours of
Intolerance related undergone blood nursing activity intolerance. exertion, nursing
to anemia and transfusion is intervention the Ask client to rate palpitations, intervention
decreased oxygen patients perceived exertion. headaches, or Hgb and Hct level
usually under bed are normal and the
Objective: carrying capacity of Hgb and Hct level dizziness or patient
Abnormal heart blood due to rest for few days will become states increased patient perceives
rate or blood decreased RBC’s. that may hinder her normal and the exertion level, are exertion at less
patient perceives that 3 on a scale of
pressure to perform her all signs of activity
exertion at less 1-10, tolerates
usual activity. Due that 3 on a scale of
intolerance and activity, AEB resp
to decrease Hgb 1-10, tolerates decreased tissue rate 12-18 breaths
level, which is the activity, AEB resp oxygenation. per minute and
rate 12-18 breaths heart rate 60-90
oxygen carrier in beats per minute.
per minute and -Monitor pulse -O2 sat of <92%
the blood, heart rate 60-90 oximetry and report indicates the need Denies any
transportation of beats per minute. O2 saturation to supplement dizziness.
oxygen to tissue Denies any
<92%. oxygen.
dizziness.
was impaired and
hypoxia develops -Assess the need for -Client may not be
thus client will fall risk precautions. able to perceive
weakness and loss
experience fatigue
of balance.
or weakness.
assessment Diagnosis inference planning intervention rationale
Ineffective Difficulty of Patients maintain
Breathing Pattern breathing occurs effective breating
Objective: because of the pattern, as
Dyspnea decreased evidenced by
Breathlessness, or concentrations of relaxed breathing at
trouble catching oxygen in the normal rate and
breath blood. depth and absence
of dyspnea
assessment diagnosis inference planning intervention rationale Evaluation