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Fatigue related to Low Hemoglobin Level

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Cues

Subjective:

“I cannot sleep at night.” as verbalized.

Objective:

Frequent yawning

Noisy environment

Need

ACTIVITY-EXERCISE PATTERN

Nursing Diagnosis

Rationale:

Anemia could cause fatigue to the patient since there is insufficient oxygen circulating in the body

Objective of Care

Within 8 hours span of care, patient will be able to make a lifestyle changes to modify fatigue, thus she will be able to:

  • Have at least 2 hours of uninterrupted rest
  • Absence of yawning
  • Verbalize feeling of being rest

Nursing Intervention

  1. Assess the patient’s nutritional intake of calories, protein, minerals, and vitamins.

R: Fatigue may be a symptom of protein-calorie malnutrition, vitamin deficiencies, or iron deficiencies.

  1. Evaluate the patient’s sleep patterns for quality, quantity, time taken to fall asleep, and feeling upon awakening.

R: Changes in the person’s sleep pattern may be a contributing factor in the development of fatigue.

  1. Reassess the patient’s usual level of exercise and physical activity.

R: Both increased physical exertion and limited levels of exercise can contribute to fatigue.

  1. Help the patient set priorities for desired activities and role responsibilities.

R: Setting priorities is one example of an energy conservation technique that allows the patient to use available energy to accomplish important activities. Achieving desired goals can improve the patient’s mood and sense of emotional well-being.

  1. Monitor the patient’s nutritional intake for adequate energy sources and metabolic requirements.

R: The patient will need adequate intake of carbohydrates, protein, vitamins, and minerals to provide energy resources

  1. Minimize environmental stimuli, especially during planned times for rest and sleep.

R: Bright lighting, noise, visitors, frequent distractions, and clutter in the patient’s physical environment can inhibit relaxation, interrupt rest/sleep, and contribute to fatigue.

  1. Help the patient develop habits to promote effective rest/sleep patterns.

R: Promoting relaxation before sleep and providing for several hours of uninterrupted sleep can contribute to energy restoration.

  1. Encourage the patient and family to verbalize feelings about the impact of fatigue.

R: Fatigue can have a profound negative influence on family processes and social interaction.

Evaluation

“Goal Partially Met”

After 8 hours span of care, patient was able to make lifestyle changes to modify fatigue, thus, she was:

  1. Not able to have 2 hours of uninterrupted sleep
  2. Yawning was not noted anymore
  3. Verbalize if feeling rested.

Four Frames Approach

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Four Frames method is the logical comprehensive history assessment in the clinical area.

  1. Presenting Complaint
    1. History of Present Condition
    2. System Review
    3. Check the Red Flag (is there any bleeding associated with the present condition)
  2. Past Medical History, Drugs and Allergies
    1. Drugs: POM, OTC, Recreational
    2. Allergies: Drugs, Penicillin, Foods, Pets, Seasonal
  3. Social and Family History (Lifestyle Factors)
    1. Smoker, Alcohol drinker (how many do they consumed per day)
    2. Occupation of the Patient.
    3. Effect of condition in life and to their activities of daily living
    4. Family health history (Diabetes, Hypertension, Asthma)
  4. Ideas, Concerns, Expectations
    1. Check the patient’s knowledge about the condition.
    2. Ask for further concerns or clarification.
    3. (Do you have any other information for me?)
    4. (Do you have any questions for me?)

Taking a Patient’s History (Nurse/Patient)

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This is a short video of a Nurse taking patient’s history. this video corresponds with the “Canadian Culture and Communication for Nurses (CCNA).

 

PRISH – Cardinal Signs of Inflammation

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Inflammation is part of the complex biological response of the immune system to harmful stimuli, damaged cells, infection or irritation of the body. It is stimulated by chemical factors released by injured cells and serves to establish a physical barrier against the spread of infection and to promote healing of any damaged tissue following the clearance of pathogens.

PRISH stands for:

  • P – PAIN
  • R – REDNESS
  • I – IMMOBILITY (Loss of Function)
  • S – SWELLING
  • H – HEAT

 

Rule of Nines

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Top 5 Performing Schools in June 2017 Nursing Board Exam Philippines

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ADPIE – The Nursing Process

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The nursing process is the procedure used by nurses to manage and deliver holistic, patient-focused care. ADPIE process is the basis of how nurses think and operate in clinical patient care.

A – ASSESSMENT

D – DIAGNOSIS

P – PLANNING

I – IMPLEMENTATION

E – EVALUATION

Assessment
Nurses use a systematic and dynamic way to collect and analyze data about a client which is the first step in delivering nursing care. Assessment includes physiological data, psychological, sociocultural, spiritual, economic, and lifestyle factors.

Diagnosis
The nursing diagnosis is the nurse’s clinical judgment about the client’s response to actual or potential health conditions or needs. The diagnosis reflects not only that the patient is in pain, but that the pain has caused other problems such as anxiety, poor nutrition, and conflict within the family, or has the potential to cause complications.

Outcomes / Planning
Planning is based on the assessment and diagnosis where the nurse sets measurable and achievable short- and long-term goals. The assessment data, diagnosis, and goals are written in the patient’s care plan that is accessible to other health professionals caring for the patient.

Implementation
The nursing care is implemented according to the care plan, so continuity of care for the patient during hospitalization and in preparation for discharge needs to be assured.

Evaluation
The continued evaluation of the nursing care plan is needed which includes patient status and its effectiveness. Modification of the plan is also applicable if needed.

Complete Physical Assessment

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this video explains the guide and steps involved in a head-to-toe health assessment for nurses.

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