Nursing Diagnosis
Potential for anemia (low number of red blood cells) related to severe blood loss as evidence by pale skin, dizziness, shortness of breath, increased pulse and exhaustion.
Assessment
Assess mental alertness and awareness
Assess skin for color and warmth
Check vital signs for blood pressure, temperature, pulse and oxygen level
Assess respiratory rate, depth, and effort
Check patients medical history to determine the occurrence of recent blood loss or trauma
Assess for pain, headache and dizziness
Assess skin for color and warmth
Check vital signs for blood pressure, temperature, pulse and oxygen level
Assess respiratory rate, depth, and effort
Check patients medical history to determine the occurrence of recent blood loss or trauma
Assess for pain, headache and dizziness
Smart Plan
By April 30, 2014 at 1500 patient skin color will be warm and pink. Respirations will be easy and be in the range of 16-18. Vital signs will be stable and patient will be able to perform daily activities without exhaustion.
Nursing Interventions
1. Monitor vital signs - to have a baseline data incase of any alteration or change in pulse and blood pressure, temperature, capillary refill and O2 levels
2. Head to Toe Assessment - to check if they are alert and oriented, if there is any pain present, bowel and lung sounds, respirations and grips and pulls.
3. Monitor and Check for bleeding- to see if there is any bleeding present and if any, the state of the bleeding
4. Patient teaching - Patients are educated about needed dietary adjustments. Patients should be taught that taking iron medication with orange juice provides the necessary vitamin C.
5. Increase intake of nutrients, and adequate fluid-to ensure a proper diet is being met and they are receiving the nutrition and fluids needed.
6. Identify and implement energy-saving techniques - encourages patient to do as much as possible, while conserving limited energy and preventing
fatigue.
2. Head to Toe Assessment - to check if they are alert and oriented, if there is any pain present, bowel and lung sounds, respirations and grips and pulls.
3. Monitor and Check for bleeding- to see if there is any bleeding present and if any, the state of the bleeding
4. Patient teaching - Patients are educated about needed dietary adjustments. Patients should be taught that taking iron medication with orange juice provides the necessary vitamin C.
5. Increase intake of nutrients, and adequate fluid-to ensure a proper diet is being met and they are receiving the nutrition and fluids needed.
6. Identify and implement energy-saving techniques - encourages patient to do as much as possible, while conserving limited energy and preventing
fatigue.
Evaluation
Patient skin color remains pink and warm. No signs of dizziness or shortness of breath. Vital signs remain stable and patient can tolerate daily activities without any exhaustion. Patient teaching and emotional support was provided and patient educated about dietary adjustments and they are being followed.