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ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: ¨ Activity ¨ Sickle cell Short term: Independent: ¨ Influences ¨ Patient reveals
intolerance anemia, choice of an increase in
¨ “Nanghihina related to or sickle After 8 hours of ¨ Assess patient’s interventions or activity
ako,kadalasan imbalance cell disease, is nursing ability to perform needed tolerance,
hindi ko matapos between one of the interventions the normal task or assistance. demonstrating a
ang mga gawain oxygen supply hereditary patient will: activities of daily reduction in
ko (I’m feeling (delivery) and causes of living. ¨ May indicate physiological
weak, I can’t even demand. anemia. Most ¨ Report an neurological signs of
complete my often seen in increase in ¨ Note changes in changes intolerance and
chores)” as people of activity tolerance balance/ gait associated with laboratory values
verbalized by the African including disturbance, vitamin B12 within normal
patient. descent, sickle activities of daily muscle weakness. deficiency, range.
cell anemia is living. affecting patient
Objective: characterized ¨ Recommend safety or risk of
by the ¨ Demonstrate a quiet atmosphere, injury.
¨ Fatigue. production of decrease in bed rest if
rigid, sickle- physiological indicated. ¨ Enhances rest to
¨ Greater need for shaped red signs of lower body’s
sleep and rest. blood cells. intolerance. ¨ Elevate the head oxygen
These of the bed as requirements,
¨ V/S taken as abnormal sickle ¨ Display tolerated. and reduces
follows: cells break laboratory values strain on the
down faster within acceptable ¨ Provide or heart and lungs.
T: 36.9 than normal red range. recommend
P: 75 blood cells, assistance with ¨ Enhances lung
R: 18 resulting in a Long term: activities or expansion to
BP: 100/80 chronic ambulation as maximize
shortage of red After months of necessary, oxygenation for
blood cells and nursing allowing patient to cellular uptake.
anemia interventions, the do as much as
symptoms. patient: possible. ¨ Although help
Sickle cell may be
anemia is a ¨ Is free from ¨ Plan activity necessary, self
form of weakness and progression with esteem is
hemolytic risk for patient, including enhanced when
anemia, which complications activities that the patient does
describes types has been patient views some things for
of anemia prevented. essential. Increase self.
caused by the levels of activities
rapid as tolerated. ¨ Promotes
destruction of gradual return to
red blood cells. ¨ Identify or normal activity
implement energy level and
Causes of saving technique improved muscle
anemia often like sitting while tone or stamina
include genetic doing a task. without undue
mutations. fatigue.
Thalassemia is Collaborative:
one of the ¨ Monitor ¨ Encourages
genetically laboratory studies. patient to do as
inherited types Hb or Hct and much as possible,
of anemia. RBC count, arterial while conserving
Thalassemia blood gases limited energy
occurs when the (ABGs). and preventing
body’s genes, fatigue.
which are
responsible for ¨ Identifies
proper deficiencies in
hemoglobin RBC components
production, affecting oxygen
become transport and
damaged or treatment needs
mutated. or response to
therapy.
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: · Acute pain · Ectopic · After 8 hours Independent: · To determine · After 8 hours
related to pregnancy is of nursing presence of of
“Masakit ang distention or gestation interventions, the · Monitor maternal hypotension and Nursing
tiyan ko” (My rupture of located outside patient will be vital signs. tachycardia interventions,
tummy hurts) as fallopian tube. the uterine relieved or caused by rupture the patient was
verbalized by cavity. The controlled. · Monitor for or hemorrhage. relieved or
patient. fertilized ovum presence and controlled.
Implants amount of vaginal · To further
Objective: outside of the bleeding. assess the present
uterus, usually situation
· Facial mask of in the fallopian · Monitor for indicating
pain. tube. increase and pain hemorrhage.
Predisposing and abdominal
· Guarding factors include distention and · Increased pain
behavior. adhesions of the rigidity. and abdominal
tube salpingitis, distention
· V/S taken as congenital · Monitor complete indicates rupture
follows: and blood count and possible intra
developmental (CBC). abdominal
T: 36.4 anomalies of hemorrhage.
P: 85 the fallopian · Provide comfort
R: 22 tube, previous measure like back · To determine
Bp: 110/90 ectopic rubs, deep the amount of
pregnancy, use breathing. Instruct blood loss.
of an in relaxation or
intrauterine visualization · Promotes
device for more exercises. relaxation and
than 2 years, may enhance
multiple · Provide patient’s coping
induced diversional abilities by
abortions, activities. refocusing
menstrual attention.
reflux , and · Provide · Diversional
decreased diversional activities are
tubal motility. activities. focusing
attention and
Collaborative: enhancing coping
· Administer with limitations.
analgesics as
indicated. · To maintain
acceptable level
of pain.
ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: · Fear related to · Dysfunctional · After 4 hrs of Independent: · Defines scope · After 4 hrs of
change in uterine bleeding nursing of individual nursing
“Natatakot ako health status. is abnormal interventions, the · Identify patient’s problem, interventions,
bigla na lang uterine bleeding patient will perception of threat separate from the patient was
akong dinugo” as in the absence report fear and represented by the physiological able to report
verbalized by the of clinical or anxiety are situation. causes, and fear and anxiety
patient. ultrasonographic reduced to a influences choice are reduced
evidence of manageable · Encourage patient of intervention. to a manageable
Objective: structural level. to acknowledge level.
abnormalities, and express fears. · Provides
· Restlessness. inflammation, or opportunity for
pregnancy. · Provide dealing with
· Increased Treatment is opportunity for concerns,
tension. usually with discussion of clarifies reality
oral personal feelings of fears, and
· Feelings of contraceptives. or concerns and reduces anxiety
helplessness Dysfunctional future expectations to manageable
uterine bleeding level.
· V/S taken as (DUB), the most · Identify previous
follows: common cause coping strengths of · Family
of abnormal the patient and members have
T: 37.2 uterine bleeding, current areas of individual
P: 90 occurs most control or ability. responses to
R: 18 often in women what is
Bp: 110/80 > 45 (> 50% of · Encourage use of happening, and
cases) and in relaxation their anxiety may
adolescents technique like deep be communicated
(20% of cases). breathing, guided to patient,
The cause is imagery. intensifying this
usually estrogen emotion.
production
unopposed by · Focuses
progesterone, attention on own
which can lead capabilities,
to endometrial increasing sense
hyperplasia. The of control.
endometrium
sloughs and · Provides active
bleeds management of
incompletely, situation to
irregularly, and reduce feelings
sometimes of helplessness.
profusely or for
a long time.
Endometrial
hyperplasia,
particularly
atypical
adenomatous
hyperplasia,
predisposes to
endometrial
cancer.