University of Perpetual Help System – DALTAAlabang-Zapote Road, Pamplona, Las Piñas City

COLLEGE OF NURSING

NURSING CARE PLAN

NAME OF PATIENT: AGE: 16 SEX: F DIAGNOSIS: DFS

CUES NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION PLANNING SELECTED

INTERVENTIONSIMPLEMENTED

INTERVENTIONS RATIONALE EVALUATION

Subjective:

“NanghihinaAko. Parang sa tuwing gigising ako mabigat ang pakiramdam ko”, as verbalized by the patient.

Objective:

Fatigue Lethargy Greater need for

sleep and rest Dry lips Pallor V/S taken as

follows:T: 36.6P: 79R: 20BP: 100/70

Activityintolerancerelated toimbalancebetween oxygensupply and demand

Anemia –

Goal:

After a month ofnursing interventions,the patient: Will be free from

weakness and risk for complications will be prevented.

Expected outcome:

After 8 hours ofnursing interventionsthe patient will: Report an increase

in activity tolerance including activities of daily living.

Demonstrate a decrease in physiological signs of intolerance.

Display laboratory values within

Independent:

Assess patient’s ability to perform normal task or activities of daily living.

Note changes in balance/gait disturbance, muscle weakness.

Recommend quiet atmosphere, bed rest if indicated.

Elevate the head of the bed as tolerated.

Provide or recommend assistance with activities or ambulation as necessary, allowing patient to do as much as possible.

acceptable range. Plan activity progression with patient, including activities that the patient views essential. Increase levels of activities as tolerated.

Identify or implement energy saving technique like sitting while doing a task.

Increase fluid intake

Collaborative:

Monitor laboratory studies. Hb or Hct and RBC count, arterial blood gases (ABGs).

NAME OF STUDENT: Columbretis, Joel C. YR./SEC./GROUP NO. : III – F, Group 1 AREA AND SHIFT: UPHSD – MC 3rd Floor Main Station