VI.
NURSING CARE PLAN
ASSESSMENT DATA
(Subjective & Objective Cues)
• Subjective:
 “ …. Gamay ra akong
ma-ihi…” as verbalized
by the patient.
• Objective:
 Edema
 Decreased Hb (8.4) /Hct
(26.2)
 Change in mental status:
restless
 Abnormal increase of
abdominal girth (77cm)
NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
Excess fluid volume Short-term Goals: Independent: Short-term
related to accumulation of Goals:
fluids in the body After 3 hours of 1. Elevate edematous extremities, change
secondary to acute thorough nursing position frequently. Goals met. After
glomerulonephritis intervention, the R: To reduce tissue pressure and risk of 3 hours of
skin breakdown.
patient will be able to: thorough
nursing
a. Gradually excrete
2. Assist and/or encourage client to turn to intervention, the
excessive fluid sides every 2 hours. patient was be
through urination. R: it aids in the mobilization of fluids to
able to gradually
easily excrete through urination. excrete
b. Demonstrate
excessive fluid
behaviors that 3. Allow client to hear running water.
would help in through
excreting R: to promote diuresis urination and
excessive fluids in demonstrated
4. Apply hot and cold compress on the behaviors that
the body.
client’s bladder (just above symphisis would help in
pubis). excreting
excessive fluids
Long- term Goals: R: to stimulate urination.
in the body.
After 2 days of 5. Encourage bed rest if ascites is
present. Long- term
thorough nursing
Goals:
intervention, the client
R: May promote recumbency-induced
will be able to: Goals met. After
diuresis
2 days of
a. Excrete
thorough
VI. NURSING CARE PLAN
completely Dependent : nursing
excessive fluids intervention, the
1. Administer diuretic (furosemide 20
as manifested by client was be
the absence of mg IVTT every 8 hours; able to excrete
edema. spironolactone 25 mg 1 tab BID), as completely
ordered excessive fluids
b. Improve the as manifested
distended R: To increase water excretion.
by the absence
abdominal girth 2. Administer albumin 20% IVTT for 30 of edema and
from 77cm to minutes every 12hours improved the
67cms. distended
R: because it helps in the shifting of
abdominal girth
fluids from ISC to IVC.
from 77cm to
67cms.
 VI. NURSING CARE PLAN
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective Cues)

• Subjective Ineffective Breathing Short Term Goals: Independent: Short-term

“ gahangakon ko ug galisod ko Pattern related to Goals:
ug ginhawa usahay, “ as accumulation of fluid in After 15 min. of nursing 1. Assist client in proper deep
the peritoneal cavity interventions, the patient breathing exercises. Goals met.After
verbalized by the patient.
secondary to Ascites will be able to: R: To promote good lung expansion. 15 min. of
nursing
a. Improve 2. Position client in Semi-fowler’s interventions,
• Objective respiratory rate position. Elevating the head of bed. the patient was
from 32cpm to 30 R: To prevent compression of the able to Improve
- Increase respiratory rate cpm. diaphragm by allowing the organs in respiratory rate
of 32 cpm (tachypneic) b. Demonstrate and the peritoneal cavity to lower down. from 32cpm to
participate on 30 cpm,
- Abnormal increase of the treatment 3. Encourage adequate rest periods demonstrated
given to relieve between activities. and
abdominal girth of 77cms
the condition. R: To avoid overexertion. participated on
c. Improve the the treatment
- Restless
client’s behavior 4. Instruct client and/or significant given to relieve
from restless to others not to allow client wear tight the condition
responsive by dresses. and improved
answering R: to promote proper lung expansion the client’s
questions that are thus, proper breathing. behavior from
being asked. restless to
Dependent: responsive by
Long-Term Goals: answering
After 1 day of thorough 3. Administer diuretic (furosemide 20 questions that
nursing intervention, the mg IVTT every 8 hours; are being
client will be able to: spironolactone 25 mg 1 tab BID), as asked.
ordered
a. achieve and
maintain normal Long-Term
VI. NURSING CARE PLAN
range of R: To increase water excretion. Goals:
respiration (15 –
22cpm) 1. Administer albumin 20% IVTT for 30 Goals partially
b. Improve the minutes every 12hours met. After 1 day
distended of thorough
abdominal girth R: because it helps in the shifting of nursing
from 77cm to fluids from ISC to IVC. intervention, the
67cms. client was able
to improve the
distended
abdominal girth
from 77cm to
67cms but fails
to achieve and
maintain normal
range of
respiration (15 –
22cpm).

ASSESSMENT DATA
(Subjective & Objective Cues)
• Subjective
“ Luya man ko ug dali ra ko
kapuyon, “ as verbalized by the
patient.
• Objective:
- Abnormal decrease of
RBC 2.96
- Abnormal decrease of
hemoglobin 7.6
- Abnormal decrease of
hematocrit 23.4
- Pale conjunctivae
- Pallor skin
- Restless
- Weak peripheral pulses
VI. NURSING CARE PLAN
NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
Ineffective Tissue Short –Term Goals: Independent: Short-Term
perfusion(peripheral) Goals.
related to decreased After 2hrs. of nursing 1. Assist patient in ambulation.
hemoglobin concentration interventions, the patient R: To promote venous return. Goals met After
secondary to anemia will be able to: 2hrs. of nursing
2. Inform the patient not to stand/sit for
interventions,
long periods.
R: Prevent venous stasis. the patient was
a. Participate and
demonstrate various be able to
ways to achieve 3. Assist patient in passive or active participate and
effective tissue range-of-motion. demonstrate
perfusion. R: To allow circulation. various ways to
achieve
b. Improve the 4. Turn to side every 2 hrs.
effective tissue
client’s behavior from R: to allow proper blood circulation
perfusion and
restless to
responsive by improved the
answering questions Dependent: client’s behavior
that are being asked. from restless to
1. Administer Packed RBC 450ml for 4
responsive by
– 6 hours, as ordered.
R: To enhance oxygen carrying capacity answering
of the body. questions that
are being
asked.
 VI. NURSING CARE PLAN

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective Cues)

Deficient Diversional After 35 minutes of Independent: Goals were met.

Subjective: Activity related to fatigue nursing interventions,
and malaise. the patient will be able > Acknowledge reality of situation and After 35 minutes
“Laay kaayo magpuyo diri sa to: feelings of the client of nursing
hospital ma’am, gusto na bia *To establish therapeutic relationship interventions,
gusto na ko makigdula sa ako > validate reality of the patient was
mga amigo,” as verbalized by environmental > Review history of activity/hobby able to:
the patient. deprivation. preferences and possible modifications.
> validate
Objective: > note impact of illness > Provide for physical as well as reality of
on lifestyle. diversional activities. environmental
> restless deprivation.
> bored > Encourage mix of desired
> Over eating activities/stimuli (music, story books). > note impact
*Activities need to be personally of illness on
meaningful for patient to derive the most lifestyle.
enjoyment.

Collaborative:

Involve occupational therapist as

appropriate.
*To help identify specific activities
to individual situation.
 VI. NURSING CARE PLAN

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective Cues)

• Subjectve: Activity Intolerance (Level Short-term Goals: Independent: Short-Term

1) related to imbalance Goals.
“gahangakon ko basta grabeh between oxygen supply After 15minutes of 1. Position client in Semi-fowler’s position.
ang dula” as verbalized by the and demand secondary to thorough nursing R: to promote proper lung expansion. Goals met. After
patient anemia intervention, the client 15minutes of
will be able to: 2. Assist client during ambulation. thorough
R: to promote circulation nursing
• Objective: a Improve his respiration intervention, the
from 32 cpm to 30 cpm.
- Abnormal decrease of 3. Encourage rest periods fro client and client was able
avoid exertion on unnecessary to improve his
RBC 2.96 b. Demonstrate
activities. respiration from
- Abnormal decrease of responsiveness by
R: to conserve energy consumption. 32 cpm to 30
hemoglobin 7.6 answering questions.
cpm and
- Abnormal decrease of
c. verbalize the activity 4. Listen to the client’s verbalization demonstrated
hematocrit 23.4
intolerance about the problem responsiveness
- pale skin
R: it will encourage verbalization of by answering
- restlessness
Long-Term Goals: feelings. questions and
- increase respiration rate
verbalized the
of 32cpm (tachypneic) After 8 hours of thorough activity
nursing intervention, the Dependent: intolerance.
client will be able to:
1. Administer Packed RBC 450ml for 4
Long-Term
a. achieve – 6 hours, as ordered.
Goals:
and R: To enhance oxygen carrying capacity
maintain of the body. Goals partially
normal met. After 8
range of hours of
respiration thorough
nursing
VI. NURSING CARE PLAN
(15 – intervention,
22cpm) the client was
b. Ambulate able to
independe ambulate
ntly without independently
problems without
in problems in
respiration. respiration.
But failed to
achieve and
maintain
normal range of
respiration (15
– 22cpm).
 VI. NURSING CARE PLAN

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective Cues)

Risk Factors: Risk for Constipation Short-Term Goals: Independent: Short-Term

related to irregular Goals:
- Two days without defecation habits After 45 minutes of 1. Encourage client to increase fiber intake
defecation thorough nursing in his diet. Goals met. After
- Restless intervention, the client R: to improve consistency of stool and 45 minutes of
- Decrease bowel sounds will be able to: facilitate passage through colon. thorough
(3 counts) nursing
a. Gradually intervention, the
2. Promote adequate fluid intake.
defecate feces client was be
R: to promote soft stool and stimulate
within the body. able to gradually
bowel activity.
defecate feces
b. Improve client’s
4. Assist client in doing Range of within the body,
status from
Motion. improved
restless to
R: to stimulate contraction of the client’s status
responsive.
intestines. from restless to
c. Improve bowel responsive and
sounds from 3 5. Encourage client on frequent improved bowel
counts to 5 ambulation; sounds from 3
counts. R: this will promote peristaltic counts to 5
movement. counts.
Long-Term Goals:
Long-term
After 1 day of thorough Dependent:
Goals:
nursing intervention, the
client will be able to; 1. Administer laxative (senna concentrates, Goals partially
PRN), as ordered. met. After 1 day
a. Maintain bowel R: to soften the stool thus, promote of thorough
habit in defecation. nursing
VI. NURSING CARE PLAN
accordance to his intervention, the
time preference. client was able
to Maintain
b. Maintain bowel bowel sounds
sounds within the within the
normal range. normal range
but failed to
maintain bowel
habit in
accordance to
his time
preference.
 VI. NURSING CARE PLAN
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective Cues)

Acute pain related to After 1 hour of nursing Independent: Goals were met.
Subjective: inflammation of the renal interventions, the patient
cortex secondary to acute will be able to: > observe nonverbal pain behavior After 1 hour of
“sakit diri dapit sa hawak…” glomerulonephrtis. R: observation may not be congruent with nursing
as verbalized by the patient. > demonstrate verbal reports interventions,
nonpharmalogical the patient was
- Pain scale of 6/10 methods that provide >provide comfort measures, quiet able to:
relief environment and calm activities
Objective: R: to promote nonpharmacological pain >demonstrate
> improve restlessness management nonpharmalogic
> restless > encourage use of relaxation techniques al methods that
> muscle guarding >verbalize the decrease such as focus ed breathing and imaging provide relief
> facial grimace whenever the of pain from 6 to 3 scale R: to distract attention and reduce tension
location of pain is touched. > improve
> .review procedures and tell patent when restlessness
treatment may cause pain.
R: to reduce concern of the unknown and >verbalize the
associated muscle tension. decrease of
pain from 6 to 3
scale
Collaborative:

Involve occupational therapist as

appropriate.
*To help identify specific activities
to individual situation.