Nursing care plan on Anemia - Assessment, Diagnosis, planning, Implementation and Evaluation

Nursing care plan on Anemia - Assessment, Diagnosis, planning, Implementation and Evaluation

1. NURSING ASSESSMENT NURSING
DIAGNOSIS
OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE DATA:
 Weakness
 Lethargy
 Decreased
exercise tolerance
 Tiredness
 Lack of Energy
 Dyspnea on
exertion

OBJECTIVE DATA:
 Pallor
 Capillary Refill
time- Prolonged
 RBC- decreased
 Hemoglobin –
decreased
 Hematocrit-
Decreased
 Mean corpuscular
volume- decreased
 Sr. Iron- decreased
 Sr. Ferritin-
Decreased
Fatigue related
to decrease
oxygen
transport to the
tissues
secondary to
decreased
haemoglobin
levels in the
blood
Client exhibits an
increase in
energy level and
reports relief
from fatigue
1. Assess the client energy levels and
ability to perform work
Assessment aids in
understand the client’s
underlying problem & plan
Interventions
Client’s Fatigue
was reduced as
evidence by
increased in the
energy levels,
absence of
Dyspnea &
increased HB
levels.











2. Monitor the vital signs especially
respiratory rate and oxygen saturation
To identify the presence of
shortness of breath and
identify the need for oxygen
therapy
3. Advice to space activities with
adequate rest periods
To conserve the energy and
prevent increased oxygen
utilisation by the tissues
4. Administer oxygen therapy as needed To meet the tissue oxygen
needs and relieve Dyspnea
5. Advice to avoid strenuous Activities To prevent energy loss
6. Advice the client to take balanced
Nutrition with all macro & micro
nutrients
To Increase energy levels
7. Educate on energy conserving
Techniques like using chair to sit &
bath, avoiding rushing & scheduling
house hold activities
To relieve fatigue
8. Administer Iron and Folic acid
supplements if needed
To increased Blood
Hemoglobin levels
9. Arrange all articles in the environment
for easy access especially the
frequently used items
To minimise workload &
fatigue

10. Monitor for any bleeding tendencies
and Replace the volume loss with
plasma Expanders or blood transfusion
as prescribed
To increase RBC & HB levels
and there by relieve fatigue

2. NURSING ASSESSMENT NURSING
DIAGNOSIS
OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE DATA:
 Anorexia
 Weight loss
 Decreased energy
to cook food and
eat
 Poor socio
economic status
 Inadequate dietary
pattern
OBJECTIVE DATA:
 Weight -
Decreased
 BMI - Under
weight
 Pallor
 Smooth Beefy
tongue
 Thin and
emaciated
 Sr. Albumin
decreased
 Sr.Iron decreased
 Hemoglobin
decreased
 Haematocrit
decreased
 Vitamin deficiency
Imbalance
nutrition less
than body
requirement
related to
inadequate
nutritional
intake
secondary to
anorexia or lack
of essential
nutrients in the
diet
Client maintains
a normal dietary
pattern with
adequate dietary
intake and a
balanced
nutrition
1. Assess the nutrition status of the client To provide nutritional
therapy as per the nutritional
requirements of the client
Client’s
nutritional
pattern was
improved as
evidenced by
weight gain and
adequate
dietary intake.






















2. Monitor weight regularly To identify the nutritional
needs of the client
3. Advice the client to take balanced
nutrition with adequate nutrients
To meet the nutritional needs
of the client
4. Advice the client to take foods rich in
iron, protein and vitamins like green leafy
vegetables pulses, fruits and meat
To maintain the nutritional
status of the client
5. Teach the client to maintain nutritional
dairy of all the foods consumed daily
To evaluate the nutritional
status and identify the need
for supplement nutrients
6. Administer iron supplements like syrup
dexorange or iron tablets and injections.
To increase the haemoglobin
level in the blood
7. Administer folic acid and vitamin
supplements as needed
To treat anaemia
8.Provide a menu plan regarding dietary
pattern to be followed
To meet the nutritional
requirement and maintain
balance nutrition
9. Advice the client to avoid strenuous
activity while not taking adequate
nutrition
To conserve energy
10.In case of poor socio economic status
orient the client to any of the nutritional
benefits schemes like ration and voluntary
agencies
To relieve poverty and
provide adequate nutrition

3. NURSING ASSESSMENT NURSING
DIAGNOSIS
OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE DATA:
 Pruritus
 Dryness
 Yellow discoloration
of skin (Jaundice)
 Skin break down
OBJECTIVE DATA:
 Jaundice
 Increased bilirubin
levels
 Skin ulcerations
 Itchy skin
 Decrease RBC and
haemoglobin levels
 Capillary refill time
prolonged
 Poor skin turgor
Impaired skin
integrity related
to decreased
tissue
oxygenation
secondary to
hemolysis of RBC
leading to
decreased
haemoglobin
levels in the
blood
Client shows
an improved
skin integrity
1. Assess the changes in skin colour,
turgor, elasticity and integrity
To provide baseline data and
plan interventions
Client’s skin
integrity was
improved as
evidenced by
wound healing
and absence of
pruritus &
jaundice.





















2. Cut short the nails of the client and
advice the client to avoid scratching
the skin
To prevent skin breakdown
3. Advice the client to take warm
bath twice a day
To meet the hygiene and
prevent infection
4. Advice the client to apply
emollients like Vaseline or zinc oxide
to the skin
To prevent itching
5. Provide sterile dressings with
aseptic technique if there is presence
of skin breakdown or injury
To prevent wound infection
6. Advice the client to take foods rich
in protein, iron and vitamin C
To increase the haemoglobin
level in the blood and
promote healing
7. Administer iron, folic acid and
vitamin supplements as needed
To treat anaemia
8.Advice the client to take lots of oral
fluids
To prevent dryness and
dehydration
9. Administer IV fluids as prescribed To prevent dryness and
improve skin integrity
10. Transfuse packed Red blood cells
as prescribed
To treat anaemia and
jaundice

4. NURSING ASSESSMENT NURSING
DIAGNOSIS
OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE DATA:
 Decreased exercise
Tolerance
 Dyspnea on Exertion
 Palpitations
 Dizziness & weakness
 Lethargy
 Insomnia
OBJECTIVE DATA:
 Pallor
 Smooth Beefy tongue
& glossitis
 Capillary refill time
prolonged
 Respiratory rate
Increased and deep
breathing
 Tachycardia even with
mild activity
 Sr.Iron decreased
 Hemoglobin decreased
 Haematocrit decreased
 Oxygen saturation
decreased
Ineffective
Tissue Perfusion
related to
decreased
hemoglobin
levels leading to
decreased
oxygen
transport to the
tissue
Client reports
an improved
tissue
perfusion
status with
adequate
tissue
oxygenation
1. Assess the vital signs and
pulse oximetry continuously
To monitor the baseline
data and identify
complications
Client had an
improved tissue
perfusion as
evidenced by absence
of pallor and a normal
capillary refill time &
vital signs.





















2. Administer oxygen therapy
via face mask as prescribed
To improve oxygenation to
the tissues
3. Administer IV fluids like
crystalloids and colloids as
needed
To maintain the fluid status
and improve tissue
perfusion
4. Advice the client to take
foods rich in iron and
vitamins
To increase Hemoglobin &
RBC levels in the blood
5. Administer iron, folic acid
and vitamin supplements as
needed
To increase Hemoglobin
and RBC levels in the blood
6. Advice the client to
prevent Injury by avoiding
sharp objects and falls
To prevent blood loss and
further decrease tissue
perfusion
7. Advice the client to avoid
strenuous activities especially
during Dyspnea and
palpitations
To conserve oxygen
8. Assess the Blood Grouping
&Rh typing of the client and
transfuse blood as prescribed
To increase hemoglobin
levels and improve tissue
perfusion

5. NURSING ASSESSMENT NURSING
DIAGNOSIS
OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE DATA:
 Decreased exercise
Tolerance
 Dyspnea on Exertion
 Inability to perform
activities of daily living
 Dizziness
 paraesthesia’s
 Lethargy & tiredness
 Muscle twitching
OBJECTIVE DATA:
 Pallor
 Increased Respiratory
rate, heart rate & BP on
exertion
 Rapid breathing during
activity
 Decreased Muscle
power
 Diaphoresis even with
mild activity
 RBC count decreased
 Hemoglobin decreased
 Haematocrit decreased
 Oxygen saturation
decreased
Activity
Intolerance
related to tissue
hypoxia
secondary to
decreased
hemoglobin
levels in the
blood causing
inadequate
oxygen
transport to the
tissues

Client
tolerates
normal
activities of
daily living
with ease
and reports a
decrease in
weakness
and fatigue
1. Assess the vital signs and
pulse oximetry continuously
To monitor the baseline
data and identify
complications
Client tolerance to
activity was increased
as evidence by the
ability to perform
daily activities with
ease and without
increase in
Respiratory, pulse
rate and Blood
Pressure.























2. Encourage alternate rest
and activity periods
To improve tolerance to
activity
3. Limit Environmental
stimuli and restrict the
number of visitors
To provide adequate rest
and conserve energy
4. Advice the client to take
foods rich in iron and
vitamins
To increase Hemoglobin &
RBC levels in the blood
5. Administer iron, folic acid
and vitamin supplements as
needed
To increase Hemoglobin
and RBC levels and thereby
increases energy to perform
activity
6. plan activities after meals
when the client has increased
energy
To increase activity
Tolerance
7. Advice the client to avoid
strenuous activities especially
during Dyspnea and
palpitations
To conserve oxygen for vital
organs
8. Assist and perform the
activities of daily living like
personal care, ambulation
etc. at the bed side of the
client if not able to perform
independently
To meet the daily activities

6. NURSING ASSESSMENT NURSING
DIAGNOSIS
OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE DATA:
 Brittle nails
 Ulcerations in the
corners of the mouth
 Glossitis (Tongue
Inflammation)
OBJECTIVE DATA:
 Complete blood count
shows decreased HB,
RBC, WBC, & Platelets
 Reticulocyte count is
low
 Blood smear shows
normocytic,
normochromic anemia
 Bone marrow
examination shows
hypocellular marrow
 Vital signs for
temperature
monitoring
Risk for
Infection related
to bone marrow
suppression
leading to
decreased
formation of
blood cells
resulting in lack
of body
defences and
tissue hypoxia
Client
prevents
infection
1. Assess the temperature at
regular intervals like every 2
hours
To identify early signs of
Infection
Client did not develop
any infection as
evidenced by healing
of mouth and tongue
ulcers and no increase
in body temperature.






















2. Teach and advice to
practice all the hygienic
measures like hand washing
frequently, bathing, oral care
and food hygiene
To prevent Infection
3. Advice the client to keep
the surroundings clean &
avoid injury from sharp
objects
To prevent skin breakdown
and treat Infection
4. Apply zytee gel to mouth
ulcers
To promote wound healing
5. Advice the client to a well-
balanced Nutrition with
increased protein & vitamins
To blood cell formation &
improve body defence
mechanism
6. Administer iron, folic acid
and vitamin supplements as
needed
To increase Hemoglobin
and RBC levels in the blood
& prevent tissue hypoxia
7. Assess the Blood Grouping
&Rh typing of the client and
transfuse whole fresh blood
as prescribed
To increase the blood cells
and increase body defences
8. Monitor the need for
Hematopoietic stem cell
transplantation and prepare
the client for the procedure if
prescribed
To cause blood cells
production

7. NURSING ASSESSMENT NURSING
DIAGNOSIS
OBJECTIVE NURSING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE DATA:
 Queries
regarding
disease
condition
 Verbalises lack
of awareness
about home
care
management
 Queries
regarding the
duration of
treatment
 Queries related
to diet,
medications and
life style
modifications
OBJECTIVE DATA:
 Illiterate about
the disease
condition
 Unaware about
the prognosis
 Looks strange
when any
procedures are
performed

Deficient
knowledge
therapeutic
regimen and long
term care
management

Client gains
knowledge
regarding the
disease
condition
treatment
protocol,
dietary and life
style changes
required
1. Assess the client’s language and
ability to follow instructions
To educate the client in
their own language and at
their own level of
understanding
Client gained
knowledge on
therapeutic
regimen and
home care
management.





















2. Educate the client on hygienic
measures
To prevent infection
3. Educate on Nutritional therapy to
increase dietary supplements of
protein, iron and vitamins
To improve blood cell
production and treat
anemia
4. Educate the client on the disease
condition, its causes, signs & symptoms
and treatment modalities
To gain knowledge on the
disease condition
5. Educate the client on the
complications of anemia like cardio-
pulmonary complications, jaundice,
skin changes, nervous dysfunction etc.
To notify the physician
when complication arises
6. Advice the client to follow the drug
regimen and administer iron, folic acid
and vitamin supplements regularly
To treat anemia
7. Administer iron, folic acid and
vitamin supplements as needed
To treat anaemia
8.Advice the client to take lots of oral
fluids
To prevent dryness and
dehydration
9. Advice the client on the need for
further blood transfusions
For complete recovery
10. Advice the client to come for
regular follow up and monitor the
complete blood count levels
For complete treatment