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ASSESSMENT NURSING INFERENCE PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTIONS
SUBJECTIVE: RISK FOR ANEMIA After 4 hours -established rapport - to gain trust After 4 hours
INFECTION of nursing and relieve of nursing
RELATED TO interventions, anxiety interventions
OBJECTIVE: INCREASE WBC DECREASE the client will the client
-the client COUNT OXYGEN IN identify -monitor vital sign, -to have a identify the
manifested the THE BLOOD interventions especially temperature baseline- proper self-
following signs to management
and symptoms: reduce/preve -stress proper hand -hand to reduce the
rWBC nt risk for washing techniques by washing is risk of having
-pale and cool infection all caregivers the primary infection
skin measure
-weakness RISK FOR against
-easy INFECTION nosocomial
fatigability infection/cro
-dryness of lips ss
-with ongoing contaminatio
n
-with limited -reverse
range of -advice the use of facial isolation is
maotion mask when interacting to an important
-labs suggest a other for clients
increased in who are
WBC count, immuno-
eosinophils, suppressed
monocytes and -simple
a decreased of -encouraged early exercises
hematocrit and ambulation, deep helps to tone
hemoglobin breathing exercises as the body and
indicated strengthen
 the body
system

-reinforced teachings -to provide

VS TAKEN AS about diet. Avoid raw optimum
FOLLOWS: meats, fruits and nutrition to
vegetables. Consume meet daily
T- 36.8C prescribed adequate needs of the
P- 80 cpm menus. client, raw
RR- 19 bpm foods can
BP-120/80 contain
mmhg microorganis
m that may
precipitate
infection
-helps
-review to the client and alleviate
so the nature of the anxiety; can
disease and the also foster
interventions needed cooperation
and
compliance
to prescribed
therapeutics

-instruct the client to -to intervene

report significant with such
changes that he may events
experience typical to a accordingly.
presence of infection
ASSESSMENT NURSING INFERENCE PLANNING NURSING RATIONALE EVALUATION
SUBJECTIVE: FLUID VOLUME UPPER GI After 30 INTERVENTIONS - to gain trust After effective
DEFICIENT BLEEDING mins of - established rapport and relieve nursing
³madali akong RELATED TO nursing anxiety intervention the
mapagod tapos DECREASE intervention patient was able
nauuhaw din´, INTRAVASCULAR gastric erosion the patient -to have a to
as verbalized FLUID will learn -monitor vital sign, baseline demonstrate
by the patient. SECONDARY TO the disease especially temperature - Helpful improved fluid
UPPER GI hemorrhage process and - Note characteristics of indetermining balance as
OBJECTIVE: BLEEDING Demonstrat vomitus or drainage. cause of evidence by
e improved gastric individually
-received Ñintravascular fluid distress adequate
patient on bed fluid balance as - Monitor I and O and - Provides urinary output
awake evidence by correlate weight guidelines for with normal
-pale and cool individually changes. fluid specific gravity,
to touch FLUID adequate replacement stable V/S,
-delayed VOLUME urinary moist mucous,
capillary refill DEFICIENCY output with - potential good skin
(3-4 seconds) normal - Keep accurate record exits turgor, prompt
-body specific of subtotals of or over capillary refill.
weakness gravity, solution/blood products transfusion of
-with ongoing stable V/S, during replacement fluids,
IVF moist therapy. [Link]
mucous, volume
VS TAKEN AS good skin expanders are
FOLLOWS: turgor, given before
T- 36.8C prompt blood
PR-80cpm capillary transfusion.
RR-19pm refill.
BP-120/80 -
mmgh activity/vomitin
- Maintain bed rest; g increases
prevent vomiting and intra
 straining at stool. abdominal
pressure and
can
predispose to
further
- Provide clear/band bleeding.
fluids when intake is - More easily
resumed. Avoid digested and
caffeinated and reduce risk of
carbonated beverages. added
irritation to
inflamed
tissues.
Caffeine and
carbonated
beverages
stimulate HCL
production,
possibly
potentiating
rebleeding
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