nursing diagnosis

Desired goal

Nursing Scientific rationale

Evaluation

Interventions
activity intolerance related Patient will show
to body weakness and increased
activity
fatigue secondary to tissue tolerance
hypoxia evidenced by patient perfuming
failing to eat by himself

by
some

activities of daily
living
throughout

1. Assess patients
ability to perform
activities of daily

To plan on which
activities
to
provide to the
patient

living
Assist

Promote

attaining activities
of daily living such
as feeding,
Carryout
nursing
interventions
blocks

To

hospitalization

Give

patient

energy

protein

and

giving foods

in

in

and enable patient

conserve energy.
promote

and
energy

and
iron

comfort

rest

conserve

Food proved energy

and
help
in
replacing worn out
red blood cells

keep supplies and

personal
articles
within easy reach

limit the number of

visitors and their

length of stay

To reduce risk of
injury
and
to
conserve energy

Enhances

rest

to

lower bodys oxygen

requirements

Observe patient
perform activities
of daily living

reducing
weakness

body

altered

tissue

perfusion Improve

and Raising the head of Promote

related to inadequate blood Maintaining Adequate bed

the

bed

as expansion

volume
and
reduced Perfusion
hemoglobin-hematocrit

tolerated

levels secondary to severe

anaemia
evidenced
by

administer
intravenous

hypoxia-reduced
capillary
refill and finger clubbing

normal saline 3000ml

in 24 hours

transfuse
blood

full

increase
uptake

lung

Check

and

cyanosis
Check
for
capillary refill

oxygen

fluids expands blood volume

whole

Increase
hemoglobin

and

hematocrit levels

monitor vital signs

especially
peripheral oxygen
saturation

To find out if
there is need for
supplemental
oxygen

Administer
oxygen
necessary

when

To improve tissue
perfusion

signs

for

Altered nutrition, less than

Improve

body requirements, related

and

Allow the patient

Food

Maintaining Adequate

to eat foods that

provide nutrients

to inadequate intake of food

due to loss of appetite,

Nutrition
status
throughout period of

is tolerated,

and calories that

the
patient

improved appetite
Check
for
cessation
of

vomiting and diarrhea

evidenced by patients verbal

hospitalization.

requires.
To provide

diarrhea
vomiting

report of weight loss

Provide

small-

intake

for

frequent
nutritious meals

the
nutrients
required per day

Check for random

blood sugar (RBS)

For baseline data

and to see if
there is need to
administer
parental feeding.

Maintain

a
pleasant and clean
environment
Provide
oral
hygiene

To

improve

appetite
To
remove
unpleasant test in
mouth
and
improve test.

Assist client with

feeding

When patient is
weak fails to feed
himself

Check

for

and

Reduce

extra

through
convection

Altered thermoregulation
hyperthermia related to

Reduce raised body

temperature
by

linen
Open

sepsis evidenced by body

temperature reading of

1cwithin 30 minutes
of
nursing

innervation

windows

Fun the room

Encourage
oral
cold fluids intake

38.4c

To allow heat loss

nearby

every four hours

To replace fluids
lost
through
insensible
heatless
Diaphoresis
Cold

fluids

i.e.

help

reduce
body
temperature
through
conduction

check
body
temperature

check for signs of

dehydration and
sweating

(Hypovolemia)Fluid and

Maintain and improve

Monitor

electrolyte imbalance

fluid and electrolyte

signs

related to fluid loss due to

vomiting, diarrhea and

balance throughout

hospitalization

vital

Vital sign changes

monitor

such as increased

pressure

blood pressure
Administer

heart
decreased

rate,
blood

pulse rate
check for signs of

inadequate intake evidenced

by poor skin turgor, rapid

intravenous fluids
normal saline and

pressure,
increased

and

dehydration
by
monitoring urine

thread pulse rate of 108

beats per minute and dark

alternate
with
ringers lactate

temperature
indicate

especially

concentrated urine.

hypovolemia.

Encourage
give oral

and
fluids
and
give
oral
rehydration salts
(ORS)

Monitor
fluid

intake and output

Administer

anti-

emetic
drugs
(promethazine
25mg
intramuscularly)

To

replace

lost

fluids
electrolytes

and

To note if there
is fluid overload.
Anti-emetics
suppresses
vomiting
center
and
vomiting

reduces

out put
check

blood
and

that

patient is taking
oral fluids
ask and monitor
for
persistent
diarrhea
vomiting

and


Risk for injury related to
dizziness and weakness

minimize the risk

of
injury
throughout period
of hospitalization

ensure

that

patients personal
belongings
are
near of reach
ask patient

To prevent falling Assess for signs of

and injury

Weak

and

improvement
dizzy environmental

find
it structure
to patient
for difficult to balance

always call
help whenever he and
want to perform activities

injury
Assess

activities
use
wheelchairs
to
transport
patient to places
remove
environmental
structure
that
might predispose
to injury and fall

perform

for
in

hypotension related to

Patient

should

reduced blood volume and

maintain

loss of fluids evidenced by

low blood pressure of

cardiac
normal

84/56mmHg

pressure or ranges

between

blood
Administer

120/80mmHg
throughout

intravenous fluids
normal
saline

hospitalization.

1000ml
bolus
within 20 minutes

adequate
output

and
blood

Take blood sample

To increase blood

Monitor

for grouping and

volume

signs

cross match and

Transfuse whole

semi
position

in

fowlers

especially

blood pressure

and put patient on

maintenance
fluids
Put patient

vital

Intravenous fluids
maintains
expands

and
blood

volume
correct

hence

hypotension.

Semi

fowler

position enables
blood to retain to
the heart

Monitor for signs

of hypertension

Knowledge deficit regarding

Patient should show

Allow

condition, prognosis,

acquisition

treatment and treatment

related to lack of exposure

knowledge
appreciate

and unfamiliarity with

hospital protocols evidenced

hospital
protocols
and procedures

by asking so many questions

of
and
the

guardian

Information

Assess

and patient to ask

enhances

acquisition

questions
Answer

all

cooperation
and knowledge by asking
informed choices
guardian and patient

and
the

on how they captured

the message

questions
clarify all

procedures
Explain that blood
taken
for
laboratory studies
will not
anemia

worsen

for

the
of

Ineffective copping

Patient

will

mechanism-Anxiety related

express/

show

to delay in blood transfusion

evidenced by patient asking

decreased level of
anxiety within 3

questions of when he is to be
transfused

hours of nursing

interventions

Assess

level

anxiety

of

through

verbal
and
nonverbal cues.
Allow patient to
express fears and
feelings
of
anxiety.

Answer
questions
he asks

Identify areas of Assess for signs

concern
and of relaxation and
provide
therapeutic

nursing care
This patient

understanding
the situation
to

ventilate out his

emotions and help
nurse
identify
areas to assist

all
which

To alley anxiety

of