NURSING CARE

PLAN
PATIENT X
40 years old
San Roque, Sta. Fe Leyte
CC : Pallor
Dx: Severe Anemia from Portal Hypertension
Gastropathy from Liver Cirrhosis from
Schistosomiasis

PROBLEM LIST
Impaired Gas Exchange related to decreased
oxygen-carrying capacity of blood as evidenced
by:
Hemoglobin 31 g/L (120-150g/L)
RBC 0.81 x 10^12/L (4.2 5.2 x 10^12/L)
RR 35cpm
PR 100bpm
Weakness and fatigue

OBJECTIVE
Within my care, the client will demonstrate
improved ventilation/ oxygenation as
evidenced by:
Respiratory rate within normal limits.
Participate in activities of daily living without
weakness and fatigue.
FHT within normal limit.

ACTIONS/ INTERVENTIONS
INDEPENDENT:
Monitor vital signs.
Monitor FHT. To determine sign of fetal distress.
Investigate reports of chest pain and increasing fatigue. Observe
for signs of increased fever. (Reflective of developing acute chest
syndrome such as chest pain, dyspnea, fever which increases the
workload of the heart and oxygen demand)
Assist in turning, coughing and deep-breathing exercise.
(Promotes optimal chest expansion and aeration of all lung fields)

ACTIONS/ INTERVENTIONS
INDEPENDENT:
Evaluate activity tolerance (Limit to those client
tolerance). (Reduction of the metabolic
requirements of the body reduces the oxygen
requirements)
Assist with ADLs and mobility as needed. (To
prevent injury)

ACTIONS/ INTERVENTIONS
COLLABORATIVE:
Monitor CBC.
Administer packed RBCs as ordered. (Increases
number of oxygen-carrying cells, improves
circulation)
Supervised compliance with medications.

EVALUATION
After my 3 days care, the client demonstrated improved
ventilation/ oxygenation as evidenced by:
Respiratory rate including other vital signs within normal limits.
RR 24cpm
PR 82bpm
Temp. 36.8 C
BP 90/60 mmHg
Participated in activities of daily living with minimal weakness
and fatigue.
FHT within normal limit.

PROBLEM LIST
Fatigue
Complaints of difficulty of breathing upon
ambulation
Report of lack of energy.
Inability to maintain usual routine.
PR 100bpm
RR 35cpm

OBJECTIVE
Within my care, the client will report improved
sense of energy and perform ADLs and
participate in desired activities at level of ability.

ACTIONS/ INTERVENTIONS
Encourage bed rest during toxic state. (Promote
rest and relaxation)
Recommend changing position frequently.
(Promote optimal respiratory function)
Identify energy conserving techniques such as
sitting while taking a bath and in doing other
ADLs. (Helps minimize fatigue)
Encourage activities as tolerated.

EVALUATION
After my 3 days care, the client reported
improved sense of energy and performed ADLs
and participated in desired activities at level of
ability.
With minimal difficulty of breathing upon
ambulation.

PROBLEM LIST
Activity Intolerance
Due to imbalanced oxygen supply secondary to low
hemoglobin level.
Body weakness and fatigue
Reports of decreased exercise activity tolerance.
Decreased Hgb and Hct levels.
Hgb 31g/L ( )
Hct 0.09u/L ( )

OBJECTIVE
Within my care, the client will demonstrate a
decrease in physiological signs of intolerance:
pulse, respiration, and BP remain within clients
normal range.

ACTIONS/ INTERVENTIONS
Assess ability to perform normal tasks/ ADLs noting
reports of weakness, fatigue and difficulty in
accomplishing tasks.
Monitor BP, pulse, respiration during and after activity.
Elevate head of bed as tolerated and encourage deep
breathing exercise. (Enhances lung expansion to
maximize oxygenation for cellular uptake)
Provide recommend assistance with activities/
ambulation if necessary.

EVALUATION
After my 3 days care, the client demonstrated a
decrease in physiological signs of intolerance:
pulse, respiration, and BP remain within clients
normal range.
PR 82bpm
RR 24cpm
BP 90/60 mmHg
Hgb 57g/L ( ) from 31
Hct 0.17u/L ( ) from 0.09

PROBLEM LIST
Risk for Injury (hemorrhage)
Risk factors:
Portal hypertension
PT control 13.9 (9.5 13.5 seconds)
BP 100/70 mmHg
PR 100bpm

OBJECTIVE
Within my care, client will maintain homeostasis
with absence of bleeding.

ACTIONS/ INTERVENTIONS
INDEPENDENT:
Assess for signs and symptoms of GI bleeding.
(GI tract is the most usual source of bleeding
because of its mucosal fragility and alterations in
homeostasis with cirrhosis.)
Observe color and consistency of stools.
Monitor pulse and BP. (An increase pulse with
decreased BP can indicate loss of circulating
blood volume.)

ACTIONS/ INTERVENTIONS
COLLABORATIVE
Monitor hemoglobin, hct, platelet and clotting
factor. (Indicators of anemia, active bleeding or
impending complications)

EVALUATION
After my 3 days care, client is able to maintain
homeostasis with absence of bleeding.

PROBLEM LIST
Risk for spread of infection related to
inadequate secondary defenses as evidence by
low hematocrit and low hemoglobin.
Hemoglobin count: 31g/L
Hematocrit count: 0.09u/L
WBC: 17.63 x 10^9/L

OBJECTIVE
Within my care the patient will be:
Able to verbalize understanding of individual risk
factors to prevent/ reduce risk of infection.
Free from infection with vital signs within normal
limit.

ACTIONS/ INTERVENTIONS
Asses, monitor and record vital signs. (To get
baseline data and to note progress of patients
condition)
Note risk factors for occurrence of infection. (To
assess causative/ contributing factors)
Stress proper hand washing technique (A first-line
defense against nosocomial infections)
Review individual nutritional needs and need for
rest. (To promote wellness)

EVALUATION
After my 3 days care, the client:
Verbalized understanding of individual risk factors to
prevent/ reduce risk of infection.
Is free from infection as evidence by:
Vital signs within normal limit.
Temp. 36.8 C
PR 76bpm
RR 24cpm
WBC 9.5 x109/L (normal)