Assessment
1. Activity / Rest
- Fatigue, weakness, general malaise.
- Loss of productivity, reduction in the passion for work.
- Low tolerance for exercise.
- The need for rest and sleep more.
- A history of chronic blood loss.
- A history of chronic infective endocarditis.
- Palpitations.
- Religious or cultural beliefs influence the selection of treatment, for example: rejection of blood transfusions.
- A history of pyelonephritis, kidney failure.
- Flatulence, malabsobsi syndrome.
- Hematemesis, Melana.
- Diarrhea or constipation
- Decreased appetite.
- Nausea / vomit.
- Body weight decreased.
- The location of pain, especially in the abdomen and head.
- Shortness of breath at rest or activity
- Menstrual changes, for example; menorrhagia, amenorrhea
- Decreased sexual function.
- Impotence.
Nursing Diagnosis
1. Impaired tissue perfusion related to a decrease in the supply of oxygen / nutrients to the cells.
Characterized by:
- Palpitations,
- Pale skin, mucous membranes dry, brittle nails and hair,
- Cold extremities,
- Changes in blood pressure, slow capillary refill,
- Inability to concentrate, disorientation.
2. Activity intolerance related to imbalance of oxygen supply
Characterized by:
- Weakness and fatigue,
- Complained decrease in activity / exercise,
- More need of rest / sleep,
- Palpitations, tachycardia, increased blood pressure.
3. Imbalanced Nutrition: less than body requirements related to failure to digest, absorption of food
Characterized by:
- Weight loss is normal,
- Decrease skin turgor, oral mucosal changes,
- Decreased appetite, nausea,
- Loss of muscle tone.
4. Constipation or diarrhea related to a decrease in the amount of food, change the digestive process, adverse effects of drug use
Characterized by:
- Any changes in the frequency, characteristics, and the amount of feces,
- Nausea, vomiting, decreased appetite,
- Abdominal pain,
- Peristaltic disorders.
