“Agkakapsuttak ken, marigatanak aggunay”as verbalized by the pt.
Ø Weak in appearance
Ø With Pale skin and conjunctiva
Ø With fatigability
Ø Looks thin in appearance
Ø Dec. Hgb. Level; 12.9 g/dl
Decreased hemoglobin level.
After 8 hours of nursing intervention, the patient will:
a. Be free from decubitus ulcer/bedsores or hematomas on the most prominent parts of the body such as the back and the buttocks.
Within 2 days of nursing interventions, the patient will:
a. Be completely independent on all ADLs and without asking assisitance with his S/O
b. Have good skin turgor
c. Have normal hemoglobin level from 104 g/L to 120g/L Hct. from 31% to 40%.
d. Reports increased sense of well being
§ Assess patients ability to perform ADLs noting reports of weakness, fatigue and difficulty in accomplishing task
§ Promote independence in self-care activities as tolerated
§ Encourage alternating activity with rest
§ Explain importance of be rest in treatment.
§ Monitor laboratory results like Hgb. & Hct.
§ Encourage increase intake of iron-rich foods.
§ Influences choice of interventions or needed assistance
§ Mild/moderate activities & improved self-esteem are promoted.
§ Minimized exhaustion & helps balance O2 supply and demand.
§ Bedrest is maintained to decrease metabolic demands thus conserving energy.
§ To identify the extent of deficiency & for better treatment plan.
§ To increase iron supplement of the body.
After 8 hours of nursing intervention, GOAL was met, as evidence by:
a. Patient’s back and buttocks are free from bedsores/hematomas respectively and free from swelling/redness as well.
Within 2 days of nursing interventions, GOAL was partially met, as evidence by:
a. The patient Verbalized partial dependence on ADLs with his S/O such as able to feed himself, assistance in toileting & bathing.
b. Demonstrates Improved skin turgor & well being
c. Able to participate in self care activities (grooming dressing)
d. Hgb and Hct level still needs to be evaluated.