Plan Cover Page
01/26/2018 Patient’s Age: 51 Gender: M
1. Decreased cardiac output R/T decreased amount of circulating blood S/T blood loss causing
2. Ineffective airway clearance R/T Bronchospasms and excess
mucus production as a result of constriction of bronchioles S/T COPD
intolerance R/T decreased
amount of circulating oxygen S/T
4.Infection, risk for R/T high glucose levels and decreased amount of circulating
leukocytes S/T Type 2 DM
risk for R/T altered mobility
S/T AKA of the LLE
Nursing-Nursing Lab 382
Nursing Plan of Care
Nursing Diagnosis (NANDA or Faculty
Nursing Interventions and Rationale
(MUST cite source
Was the goal met?
Problem resolved or prevented?
Should plan be: Continued? Revised? Terminated?
ED notes 01/20/2018 1800
“Pt. had a syncope episode during discharge while trying to get up from the
wheelchair to the car”
01/26/2018 1600 Pt. states
that they feel tired easily
-01/24/2018 Hgb 8.4
-01/24/2018 Hct 24.8
-01/24/2018 Pt. lost 400cc
of blood from bleeding at the chest port site.
the nurse can manipulate): decreased amount of circulating blood
blood loss causing symptomatic anemia.
Expected Pt. Goals & Outcomes:
-Have Improved cardiac
-Maintain cap refill 3 sec indicates decreased cardiac
output. It also indicates adequate perfusion to the extremities which is also
a goal for the pt.
2. Observe for Cyanosis on
the mucus membranes q2hrs.
-Cyanosis on mucus membranes would
indicate inadequate perfusion which is caused by a decreased cardiac output.
Pink and moist would indicate adequate perfusion.
3. Monitor HR q4hrs
-HR affects the amount of blood that is
pumped out, increased HR indicates decreased cardiac output because there is
not enough time to fill up the ventricles before the heart pumps the blood
4. Monitor Hgb, Hct, and
RBC levels daily.
– Although it may take a while for these
levels to go back to normal, an increase would indicate the level of
effectiveness of the therapy used.
5. Administer Ferrous
Sulfate 325mg PO TID.
med provides Iron which is an essential mineral needed to make hemoglobin
which is a component of RBCs.
of Development: Middle adulthood: Generativity vs Stagnation.
General health history:
2. Conditions that prevent normal
functioning: (physical, mental, etc.):
3. Alcohol/drug use: yes, x no,
amount : ___________________________
Tobacco use: x yes, no, amount (packs/day):_2__, years: Smoked for 30 years before
he quit two years ago.
5. Major medical diagnosis:Symptomatic
6. Surgical Procedure: Removal of central line,
concerns: Pt. states that he is concerned about how his health is making him
dependent on others.
8. Perception of current illness:
states that his health has been deteriorating fast, he is concerned not only of
this hospitalization but his overall health. He is aware that his acute blood
loss also affects other illnesses that he is already diagnosed with.
9. Cultural beliefs related to health:
10. Pathophysiology:(include specific source using
APA format) :
This is a condition in which
the blood has low levels of Hgb, Hct, and RBC’s.
This reduces the amount of
circulation oxygen available for the body.
The patient therefore
presents with symptoms of fatigue, SOB, dizziness, headache, or irregular
heartbeat. This diagnosis is confirmed by a blood CBC test which provides the
levels of Hgb, Hct, and RBC’s. Treatment of anemia depends on the type of
anemia the patient has been diagnosed with. The different types of anemia
include: iron deficiency anemia, vitamin B12 deficiency, folic acid deficiency
anemias. In this pt’s situation, the he has anemia due to acute blood loss.
Treatment will therefore involve a blood transfusion, iron infusion, or iron
supplements. Treatment is long term and will require continuous monitoring of
RBC’s, Hgb, and Hct levels until they are within the normal range.
Hagler, D., Lewis, S. M.,
& Dirksen, S. R. (2017). Clinical
companion to Medical-surgical nursing: assessment and management of clinical
problems. St. Louis, MO: Elsevier.
Pt orientated to place, time and
Round, equal, reactive to light.
Able to hear verbal instructions
during the assessment
(soft, firm, distended, tender)
Able to feel sensation when touched
of emesis (clear, green, yellow, red, coffee ground)
Loose brown stools
1600 BP 126/92
2000 BP 120/90
1600 HR 77
2000 HR 70
1600 Temp 98.6
2000 Temp 98.3
+2/4 in BUE
+2/4 in RLE
Unable to assess LLE d/t AKA
No edema in RLE
No edema in BUE
Unable to assess LLE d/t AKA