UNIVERSITY of the ASSUMPTION
                                                Unisite Subdivision, Del Pilar, City of San Fernando, 2000 Pampanga, Philippines
 
COLLEGE OF NURSING
LEVEL II
 RELATED NURSING EXPERIENCE 109
NURSING CARE PLAN
 
 
  Patient:                                                                                            Gender: Female                                                      Age: 
  Date of Admission:  January 22, 2022                                                                                                                        Case:         

Assessment Diagnosis Scientific Planning (Goal Interventions Rationale Evaluation

Explanation Setting)
Subjective Cues: Fatigue During After 8 hours of nursing Independent . After 8 hours of nursing
The patient related to pregnancy, the interventions the  Establish a  To establish rapport interventions the patient
verbalizes: decreased volume of patient will be able to: therapeutic and to promote shall have:
 Have had hemoglobin blood relationship with the relaxation as well as
amenorrhea since increases. This 1. verbalize client cooperation. 1. verbalized
secondary
she was 7 months. means that understanding on understanding on
to anemia
 Feels weak and more iron and the use of energy  Monitor and assess  Low levels of the use of energy
during
easily gets tired vitamins are conservation. vital signs hemoglobin, the conservation.
pregnancy.
since the last 3 required protein that carries
months and because the 2. verbalize reduction oxygen throughout 2. verbalized reduction
gradually increases body utilizes the body, can also of fatigue, as
of fatigue, as
for the past 15 days. iron to make cause anemia. evidenced by reports
evidenced by reports
 Have had a hard hemoglobin, a Whatever the cause,
of increased energy of increased energy
time breathing for protein in red there is less oxygen
and ability to and ability to
the last 15 days. blood cells that available, resulting in
Evidence by easily transports perform desired perform desired
 feels out of breath oxygen to the activities. weakness, dizziness, activities.
after climbing 2 tissues. and shortness of
flights of stairs. 3. Display laboratory breath.
 Is not experiencing values (Hgb/Hct) 3. Displayed laboratory
any palpitations within acceptable  Assess the specific  Tissue hypoxia values (Hgb/Hct)
or chest pain. range. cause of fatigue caused by normocytic within acceptable
 Not taking iron anemia is the specific range.
folate prophylaxis. cause of fatigue;
4. Plan a schedule to
however, other
balance daily activity 4. Planned a schedule
medical problems
The baby uses and rest to balance daily
Objective Cues: might also
the mother’s activity and rest
 Fatigue compromise activity
red blood cells 5. Participate in
 Hair loss, dry tolerance.
for growth and recommended 5. Participated in
and brittle.
development, treatment program recommended
 Conjunctival  Assess the client’s  Fatigue can make it
especially in
pallor (e.g.iron theraphy, ability to perform difficult for a client to treatment
the last 3
 Pale skin oxygen theraphy) activities of daily participate in self- program(e.g.iron
months of
 Platonychia living (ADLs) and the care and perform theraphy, oxygen
pregnancy.
visible in nails. 6. Identify foods that is demands of daily their societal theraphy)
Apex beat: 5 rich in iron living obligations, such as
working outside the 6. Identified foods that
house.
V/S as follows: is rich in iron
BP: 120/80 mmHg  Monitor hemoglobin,  Reduced RBC indices
Temp.: 36.5°C hematocrit, RBC are associated with
PR: 80 beats per min Therefore, the counts, and reductions in the
RR: 20 breaths per pregnant reticulocyte counts blood's oxygen-
min mother needs carrying ability.
double the Comparing serial
amount of iron laboratory values is
than critical for evaluating
nonpregnant the client's
women as the progression or
body demands deterioration and
this iron to identifying changes
make more before they become
blood to supply life-threatening.
oxygen to the
baby.  Energy reserves may
 Assist the client in be depleted unless
developing a the client respects the
schedule for daily body’s need for
activity and rest. increased rest.

 A plan that balances

 Stress the periods of activity
Women who
importance of with intervals of rest
don't have
frequent rest periods can assist the client in
enough iron
completing desired
stores or get
tasks without being
enough iron
fatigued.
during
pregnancy,
could develop  To use the available
iron-deficiency  Educate energy- energy to complete
anemia. conservation desired activities,
techniques. clients and caregivers
may need to develop
skills such as
delegating duties to
others, defining
priorities, and
clustering care.
Without Organization and
enough iron, time management can
the body can't help in the client's
produce energy conservation
enough and tiredness
hemoglobin. As reduction.
a result, the
woman
experienced
extreme fatigue
as she couldn't  Encourage patient
transport to continue iron
oxygen therapy for a total
effectively therapy time (6
months to a year),
even when fatigue
is no longer
present.
References:

https://  Explain the

www.mayoclini importance of iron
c.org/healthy- replacement/supple
lifestyle/ mentation.
pregnancy-
week-by-  Educate the client
week/in- and the family
depth/anemia- regarding foods rich
during- in iron (organ and
pregnancy/art- other meats, leafy
20114455 green vegetables,
molasses, beans).

https://  Advise patient to

www.cedars- take iron
sinai.org/ supplements an hour
health- before meals for
library/ maximum
diseases-and- absorption; if gastric
conditions/a/ distress occurs,
anemia-in- suggest taking the
pregnancy.html supplement with
meals — resume to
between-meals
schedule if
 symptoms subside.

 Inform patient that

iron salts change
stool to dark green or
black.

Dependent:

 Provide
supplemental oxygen
therapy as needed.

 Administer oral iron

medication as
prescribed by the
physician.
Collaborative:

 Refer the client and

family to an
occupational
therapist.

electronically. Note
variability, periodic
changes, and
baseline rate.Assess
condition of the oral
cavity. Note and record
body build, age,
weight/height,
strength, and
activity/rest pattern.