SUBJECTIVE:

-Client: 22 years old,

male
-prior to consultation,
patient experiences easy
fatigability and weakness
-patient reported chest
pain and dyspnea upon
heavy activity
OBJECTIVE:
VITAL SIGNS:
BP: 100/60, sitting
HR: 103 beats/minute
(regular in rhythm)
RR:
24
breaths/min
(regular in rhythm and
depth)
T 38.6 C, axillary
-well nourished
-conscious,
awake,
oriented to time place
and person
Pulse grading 1+ on
upper extremities, 1+ on
lower extremities, pale
fingernailbeds, delayed
capillary refill
Lower extremities, cool
to touch, (-) numbness,
delayed capillary refill on
toenails,
(+)
bipedal
edema
Contraptions:
Peripheral line via L
cephalic vein infused
with 1L PNSS to run for
12h @ 41-42gtts/min
Labs:

Activity
intolerance
r/t
decreased
oxygen carrying
capacity
secondary
to
anemia

Anemia is a medical
condition in which the
red blood cell count
or hemoglobin is less
than normal. The normal
level of hemoglobin is
generally different in
males and females. For
men, anemia is typically
defined as hemoglobin
level of less than 13.5
gram/100 ml and in
women as hemoglobin of
less than 12.0 gram/100
ml.
These definitions
may
vary
slightly
depending on the source
and
the
laboratory
reference used. (Porth,
2005)
Sever anemia, as what is
experienced
by
my
patient, is a significant
factor to his level of
tolerance
of
activity.
Activities done in our
daily
routine
require
energy
and
oxygen.
Oxygen
supplies
the
necessary fuel for the
muscles to work and for
the proper functioning of
the system. But with the
case of my patient, the
defect is not on the
oxygenation, ventilation
per se, but on the
hematologic
system
wherein there is marked
decrease in the oxygen
carrying capacity of the

GOAL: By the end of

the
nursing
interventions,
the
patient will report
marked increase in
activity tolerance.
OBJECTIVES: By the
end of the nursing
interventions,
the
client and caregiver
will be able to:
Activity tolerance
0005
a. Monitor
pulse
and respiratory
rate
upon
activity
b. Maintain
a
steady
walking
pace
c. Improve walking
distance
d. Able to speak
with
physical
activity
Energy
Conservation 0002
e. Recognize
energy limitation
f. Use
naps
to
restore energy
g. Balances activity
and rest
h. Organizes
activities
to
conserve energy
i. Maintains
adequate

Vital signs monitoring 6680

Establish baseline data for comparison
upon activity
a. Monitor vital signs per activity
Activity Therapy 4310
b. Demonstrate proper pulse and
respiratory monitoring before and
after activity.
c. Facilitate
activity
based
on
patients tolerance
d. Encourage
succeeding
improvement of walking distance
per activity session
e. Assist
with
regular
physical
activities
Energy Management 0180
f. Teach
organization
of
daily
activities
g. Encourage
verbalization
of
physical limitations upon activity
h. Promote bed rest
i. Perform passive/active ROM to
relax muscles
j. Instruct patient and significant
others on the signs and symptoms
of fatigue that require reduction of
activity
Nutrition
k. Discuss components of proper nutrition.
Proper nutrition can lead to better
perfusion of necessary nutrients vital to
functioning.
a. explain functions of CHO, CHON and Fats
b. enumerate possible sources of CHO,
CHON and Fats
c. explain importance of proper nutrition
d. encourage to plan meals for the client
COLLABORATIVE:

After
the
nursing
interventions,
the caregiver
and/or
the
client will:
properly
Monitor pulse
and
respiratory
rate
upon
activity

Maintain a
steady
walking pace

Improve
walking
distance

Able to
speak
with
physical
activity

Recognize
energy
limitation

Use naps
to
restore
energy

Organizes
activities
to
conserve
energy

CBC as of Aug. 06,2012

Low Hgb
Low RBC
Low HCT
High RDW

SUBJECTIVE:
-client is 22 years old,
male
-verbalized depression on
current disease state
-verbalized having no
control with his existing
condition
-reported that he feels
insufficient in being the
breadwinner
of
the
family due to existing
disease condition
-reported that he feels
tired easily leading to
shorter working hours
and lesser earnings
OBJECTIVE:
-worried, oriented
-passivity

system brought about by

the decreased RBC count
and hgb and hct. This
would then affect the
oxygen distribution and
utilization which makes
the muscles deprived of
the sufficient oxygen,
which then causes the
easy
fatigability
and
activity intolerance of
the patient.

Powerlessness
related
to
existing
debilitating
condition
secondary
to
bicytopenia with
severe anemia

This is the perception

that ones own action will
not significantly affect an
outcome, the disease
condition to be specific
with the case of my
client. The client feels
that
the
disease
condition renders him
insufficiency in working
and earning for his
family. He perceives he
lacks control over the
situation since he cant
address
his
current
problem on his health.

j.

nutrition
Reports
adequate
endurance
activity

for

Administer
medications
and
blood
transfusions as prescribed.
Refer to physical therapists for exercise
program

Maintains
adequate
nutrition

Reports

adequate
endurance for
activity

GOAL: at the end of

the
nursing
interventions,
the
client will be able to
express
sense
of
control
over
the
present situation.
OBJECTIVES: by the
end of the nursing
interventions,
the
client will be able to:
Perceived Control
1702
1. Believe that own
actions
control
health outcomes
2. Requests
involvement
to
health decisions
3. Perceived
responsibility for
health decisions

Self responsibility facilitation 4480

1. Determine whether patient has
adequate knowledge about the
disease condition
2. Encourage
verbalization
of
feelings,
perceptions
about
assuming responsibility
3. Encourage
independence,
but
assist when unable to perform
4. Provide positive feedback for
accepting personal responsibility
5. Show concern for client as a
person

After
the
nursing
interventions,
the client will
be able to:

Believe
that
own
actions
control health
outcomes
Requested
involvement
to
health
decisions
Perceived
responsibility
for
health
decisions