Cebu Normal University
College of Nursing
Cebu City
Mission-Vision: Care Using Knowledge and Compassion
NCP Scoring System 10 pts Defining Characteristics 3 pts Intervention 3 pts
Nursing Dx 2 pts Outcome 1 pt Bi!iography 1 pt "at !east # references$
C!ient%s Name& 'e!anie Bara(uia Barateria Patient Care C!assification& "P!ease chec)$
*ge& 22 y+o Sex& ,ema!e Civi! Status& Sing!e -e!igion& Catho!ic ........ /ho!!y Compensatory& Pts+ therapeutic se!f0care is accomp!ishe1 y nurse
*!!ergies& ,oo1& None ........ Partia!!y Compensatory& Pt+ performs some se!f0 care measures
Drug& None ........ Supportive 21ucative& Pt+ accomp!ishes se!f0care measures
Diet& Diet as 3o!erate1 C!inica! Division an1 Be1 No+ 4S''C 5 /ar1 6 "Be1 72 *$
Date of *1mission& 8anuary 3 2011 5 1& #3 pm Name of Physician& Dr+ Dianne 'eri!!es
Diagnosis& 92P1 "1101$ S:P NSD NID ;: retaine1 p!acenta in septic shoc)< hypovo!emic Name of Stu1ent& 2rvin =y!e P+ Osmena
Shoc)< 2
o
to severe anemia
DEFNN! C"#$#C%E$&%C& 'E"#V($#) (U%C(ME N%E$VEN%(N #ND $#%(N#)E
'E"#V($#) (U%C(ME
*DE#)+
NU$&N! D#!N(&&
,atigue re!ate1 to 1ecrease perfusion of
oxygen an1 nutrients to 1ifferent o1y parts
2
o
to impaire1 oxygen carrying capacity of
the !oo1+
Su>ective Cues&
?Pirmi !ang )apoy a)ong giati og sa)it og
)a!a;asan isan gasige ra )og og hig1a@<
as vera!iAe1
O>ective Cues&
B receive1 patient !ying on e1< a;a)e an1
coherent
B ;ith I4, C 3 PNSS I D E =4O infusing
;e!! at !eft han1 ;ith F#0 cc remaining !eve!+
B genera! o1y ;ea)ness note1
B seen: note1 patient to e fre(uent!y !ying
at e1
B note1 vera!iAation of unremitting an1
over;he!ming !ac) of energy
B hematocrit is 0+11 D:D
&"($% %E$M !(#)
*fter G hours of nursing
intervention< patient ;i!! e
a!e to vera!iAe ac(uire1
)no;!e1ge aout current
me1ica! con1ition an1
enumerate ;ays to prevent
overexertion+
)(N! %E$M !(#)
*fter 3 1ays of nursing
intervention< patient ;i!! e
a!e to perform activities of
1ai!y !iving an1 other se!f0
care activities ;ith minima!
assistance
NDE,ENDEN% N%E$VEN%(N&
IB P!an activities of 1ai!y !iving "*DDs$ an1 1ai!y exercise
sche1u!es ;ith input from the patient+
-B -ea!istic sche1u!es ase1 on the patient%s input promote
participation in activities an1 a sense of success+
SB Ne;fie!1 et a!+ Cox%s C!inica! *pp!ication of Nursing
Diagnosis+ #
th
21+ p 371
IB Instruct the patient in stress re1uction techni(ues+
-B 'enta! an1 physica! stress contriute great!y to a sense
of fatigue
SB Ne;fie!1 et a!+ Cox%s C!inica! *pp!ication of Nursing
Diagnosis+ #
th
21+ p+ 372
IB Provi1e fre(uent rest perio1s+
-B *!!o;s patient to gra1ua!!y increase strength an1
to!erance to activities+
SB Ne;fie!1 et a!+ Cox%s C!inica! *pp!ication of Nursing
Diagnosis+ #
th
21+ p+ 372
IB avoi1 sensory over!oa1 or sensory 1eprivation+ Provi1e
1iversiona! activities+
-B Sensory 1eprivation can 1ep!ete energy storesH
1iversiona! activities he!p prevent over!oa1 or 1eprivation
y focusing the patient%s concentration on an activity he
'')(!$#,"-
B Ne;fie!1 et a!+ "200I$ Cox%s
C!inica! *pp!ication of Nursing
Diagnosis+ #
th
21+ ,* Davis+
Phi!a1e!phia+
B Doenges et a! "200F$
Nurse%s Poc)et 9ui1e 11
th
21+
,* Davis+ Phi!a1e!phia
B Doenges et a! "2006$
Nursing Care P!ans 6
th
21+
,* Davis+ Phi!a1e!phia
B Pi!!iteri< *1e!e "2006$
'aterna! an1 Chi!1 Jea!th
Nursing+ #
th
21+ Dippincott
/i!!iam an1 /i!)ins+
Phi!a1e!phia+
B Sme!tAer an1 Bare "2006$
Brunner an1 su11arth%s
B hemog!oin is 0+2G g:D
)aboratory $esults
Jematocrit 5 0+11 D:D
Jemog!oin 5 0+2G g:D
%.eoret.i/al 'asis
-e1 !oo1 ce!!s or 2rythrocytes are the
most common type of !oo1 ce!! an1 is the
principa! means of carrying oxygen to the
o1y tissues via the !oo1 f!o; of the
circu!atory system+ 3he main function of the
re1 !oo1 ce!! is to carry oxygen+ 3he
carrying capacity of the re1 !oo1 ce!! to
comine or carry oxygen is 1ue to a protein
ca!!e1 hemog!oin+ 3hus< an a!teration to its
pro1uction< form:structure< passage;ay an1
hemog!oin contentcan !ea1 conse(uent!y
to the a!terations of its functions an1
importance+ It may !ea1 into 1ecrease1
perfusion of oxygen an1 nutrients to the
tissues as manifeste1 y a!tere1
consciousness< pa!!or extremities:mucous
memranes< 1iAAiness an1 even cyanosis+
Because there ha1 een an a!teration in the
supp!y of oxygen in other o1y parts< it may
resu!t to the a!teration of the specific
function of that particu!ar o1y part since
oxygen is a vita! e!ement for it to function+
9enera!!y spea)ing< it may e manifeste1
y 1ecrease1 to!erance in activities<
1yspnea in exertion< 1iAAiness an1 fatigue+
Source& Sme!tAer an1 Bare "2006$ Brunner
an1 su11arth%s 'e1ica!0Surgica! Nursing+ 6
th
21+ Dippincott /i!!iam an1 /i!)ins+
Phi!a1e!phia+
or she persona!!y en>oys+
SB Ne;fie!1 et a!+ Cox%s C!inica! *pp!ication of Nursing
Diagnosis+ #
th
21+ p+ 372
IB 3each the patient re!axation techni(ues
-B 3echni(ues in1uce a restfu! state an1 can e use1 for
short perio1s of rest as ;e!! as more exten1e1 perio1s of
rest+
SB Ne;fie!1 et a!+ Cox%s C!inica! *pp!ication of Nursing
Diagnosis+ #
th
21+ p+ 372
IB 3each the patient to use music of preference 1uring rest
perio1s+
-B *ssists ;ith re!axation
SB Ne;fie!1 et a!+ Cox%s C!inica! *pp!ication of Nursing
Diagnosis+ #
th
21+ p+ 372
IB P!an return of ;or) on gra1ua! asis
-B Provi1es gra1ua! return to activities< an1 1ecreases
!i)e!ihoo1 of fatigue
SB Ne;fie!1 et a!+ Cox%s C!inica! *pp!ication of Nursing
Diagnosis+ #
th
21+ p+ 372
IB *ssist patient ;ith grooming activities
-B Promotes the patient%s sense of contro!< an1 enhances
se!f0esteem
SB Ne;fie!1 et a!+ Cox%s C!inica! *pp!ication of Nursing
Diagnosis+ #
th
21+ p+ 372
DFE,ENDEN%0 C())#'($#%VE
IB -efer to !oca! exercise center for assistance ;ith regu!ar
exercise p!an
-B -egu!ar exercise 1ecreases fatigue+
SB Ne;fie!1 et a!+ Cox%s C!inica! *pp!ication of Nursing
Diagnosis+ #
th
21+ p+ 372
IB Co!!aorate ;ith the 1iet therapist for in01epth 1ietary
assessment an1 p!anning+
-B *1e(uate< a!ance1 nutrition assists in re1ucing fatigue+
SB Ne;fie!1 et a!+ Cox%s C!inica! *pp!ication of Nursing
Diagnosis+ #
th
21+ p+ 372
IB Co!!aorate ;ith the other memers of the hea!th care team as
in1icate1
-B Offers input from team memers to safegaure1 the
c!ient%s progress+
SB Ne;fie!1 et a!+ Cox%s C!inica! *pp!ication of Nursing
Diagnosis+ #
th
21+ p+ 372
'e1ica!0Surgica! Nursing+ 6
th
21+ Dippincott /i!!iam an1
/i!)ins+ Phi!a1e!phia+