NURSING CARE PLAN

Cues Nursing Diagnosis Nursing Goal/ Nursing Intervention Rationale Evaluation

Objective
S – “Dili man ko Sleep deprivation related to After 8 hours of Independent: 1. Provide After 8 hours of
makatug te, uncomfortable sleeping nursing Dependent: comparative nursing
magmata-mata environment. interventions, the 1. determine client’s baseline. interventions, the
man ko”, as stated patient’s SO will usual pattern and 2. Sense of goal was met, pt’s
by the patient. Scientific Basis: report expectations fullness and S.O. reported
Sleep deprivation is of improvement in 2. recommend satiety improvement in
O – irritability particular concern for the sleep/rest pattern bedtime snack promotes sleep/rest pattern of
- swelling eyelids clients in critical care unit. of her child. (protein, simple sleep and her child.
noted The noise level, 24 hour carbohydrate, and reduce
- unable to sleep lighting and frequency of Specific outcomes: low fat) for young likelihood of
noted caregiver interruptions 1. Pt’s SO will children 15 – 30 gastric upset.
Initial v/s are as create sensory overload and identify minutes before 3. To identify if
follows: sleep deprivation. Sleep individually retiring medications
T - 38°C onset difficulty is a common appropriate 3. review medications are found to
P – 84bpm problem in hospitals because interventions being taken and be interfering.
R – 30cpm of strange environment and to promote their effects on 4. To reduce
the anxiety associated with sleep. sleep, suggesting stimulation so
illness and hospitalization 2. Verbalized modifications in client can
understandin regimen. relax.
Reference: g of sleep 4. recommend quiet 5. It helps
Medical- surgical disorder.. activities, such as identify
Nursing: Clinical 3. Stable v/s: reading, listening to appropriate
Management for positive T – 36.5 -37.5 soothing music in options.
Outcomes; 7th Edition; Vol °C the evening. 6. To document
1; Black and Hawks pp.516- P – 70 – 80 bpm 5. determine symptoms
517 R – 20 – 25cpm interventions client and identify
has tried in the factors that
past. are interfering
6. instruct clients S.O. with sleep.
to keep a sleep – 7. To help deal
wake log. with
Collaborative: psychological
1. refer to support stressors and
 group/counselor or when problem
sleep specialist. is
unresponsive
to
interventions.
NURSING CARE PLAN

Cues Nursing Diagnosis Nursing Goal/ Nursing Intervention Rationale Evaluation

Objective
S – “Dili lage ni sija Risk for imbalanced After 8 hours Independent: 1. all factors that
hingaon day labi na nutrition; less than nursing 1. Determine client’s ability can affect
ug utan as verbalized body requirements interventions to chew, swallow and ingestion and
by the pt’s S.O. related to , the taste food. Evaluate teeth or digestion of
patient‘s S.O. and gums for poor oral nutrients
SCIENTIFIC BASIS: will health 2. To determine
O – Loss of appetite Pain is an verbalized 2. Ascertain understanding informational
noted thin in unpleasant and understandin of individual nutrition needs of
appearance noted. emotional g of needs. clent/SO
- irritability and experience arising causative 3. discuss eating habits 3. To appeal
restlessness noted from actual or factors when including preferences and clients
- v/s are as follows: potential tissue known and intolerances. likes/dislikes.
T – 38°C damage or described necessary 4. Assess drug interactions, 4. That they may
P – 84 bpm in terms of such interventions disease, effects, allergies, be affecting
R – 30 cpm damage; sudden or . use of laxatives. appetite, food
slow onset of any 5. Note age, body, build, intake or
intensity from mild to Specific strength, activity or rest absorption.
severe with an outcomes level, etc. 5. Helps
anticipated or 1. pt’s S.O. 6. evaluate total daily food determine
predictable end and will intake. Obtain daily of nutritional
a duration of less demonstr calorie intake, patterns needs.
than 6 months. ate and time of eating. 6. To reveal
behaviors 7. use flavoring agents (e.g. possible cause
REFERENCE: about the lemon and herbs) if salt is of
Nurse’s Pocket Guide improvem restricted. malnutrition/ch
Diagnoses, ent of her 8. Encourage client to anges that
Prioritized child choose food/have family could be made
Interventions and 2. Stable v/s: member bring food that in clients
 rationales 11th T – 36.5 seem appealing. intake.
edition; -37.5 °C 9. Promote pleasant, 7. To enhance
p 498 P – 60 – 100 relaxing environment, food
bpm including socialization satisfaction and
R – 12-20 when possible. stimulate
cpm 10. Prevent/minimize appetite.
BP – unpleasant odor/sight 8. To stimulate
120/80mmH appetite.
g 9. To enhance
intake.
10. May have
a negative
effect on
appetite/eating.

NURSING CARE PLAN

Nursing Nursing Goal/

Cues Nursing Interventions Rationale Evaluation
Diagnosis Objective
S – “Maglisod lage Ineffective airwa After 8 hours Independent: 1. indicative of Goal was completely
ko ug ginhawa te, clearance related nursing 1. Monitor respiration respiratory distress met. After 8 hours of
nya gahi ahung to retained interventions, the and breath and /or nursing interventions,
ubo”, as secretions. patient will exhibit sounds, noting accumulation of the patient exhibited
verbalized by the effectively airway rate and sounds secretions. effective airway
patient. Scientific Basis: clearance. (e.g. tachypnea, 2. To determine ability clearance.
The retention crackles) to protect own
O – conscious, of secretion and Specific outcomes: 2. Evaluate client’s airway.
coherent subsequent The patient will: cough/gag and 3. To open or maintain
- unproductive obstruction 1. Verbalize swallowing ability. open airway in at
cough noted ultimately cause understanding 3. position head rest or
- febrile the alveoli distal to of causes and appropriate for compromised
-restlessness the obstruction to therapeutic age/condition. individual.
noted collapse. management 4. Elevate head of 4. To take advantage
- body malaise Inflammatory regimen. bed/change of gravity
noted scarring or fibrosis 2. demonstrate position every two decreasing pressure
- v/s are as replaces behaviors to hours and prn. on the diaphragm
follows: functioning lung improve or 5. Encourage deep and enhancing
T – 38°C tissue. In the time maintain clear breathing and drainage
 P – 84 the patient airway. cough exercises; of/ventilation to
bpm develops 3. stable v/s: splint chest. different lung
R – 30 respiratory T – 36.5- 6. Encourage/provide segments.
cpm insufficiency with 37.5°C opportunity for 5. To maximize effort.
reduced vital P – 70-80 rest, limit 6. To prevent reduce
capacity, bpm activities to level fatigue.
decreased R – 20-25 respiratory 7. To report changes
ventilation, and an cpm tolerance. in color, amount in
increased ratio of 7. Provide the event that
residual volume to information about medical intervention
the total lung the necessity of maybe needed to
capacity. raising and prevent/treat
expectorating infection.
REFERENCE: secretions versus 8. to improve cough
Brunner & swallowing them. when pain is
Suddarth’s Collaborative: inhibiting effort .
Textbook of 8. administer (caution:
Medical and analgesic as overmedication can
Surgical Nursing, ordered depress respiration
11th Edition; Vol. 1 and cough efforts).
pp. 709
NURSING CARE PLAN

Cues Nursing Diagnosis Nursing Goal/ Nursing Intervention Rationale Evaluation

Objective
S – “maglisud ko Activity intolerance After 8 hours Independent: Goal was
ug related to impared nursing 1. Note presence of factor 1. Fatigue affects completely met.
ginhawa te, respiratory function. interventions, contributing to fatigue both the clients After 8 hours of
usahay kay the patient/pt’s (e.g. age, acute or actual and nursing
pungahan ko” as Scientific basis: SO will use chronic illness, heart perceived ability interventions, the
verbalized by An insufficient identified failure) to participate in patient/pt’s SO
the physiological or techniques to 2. Evaluate client’s actual activities. used identified
patient. psychological energy enhance activity and perceived 2. Provides, techniques to
O – conscious, to endure or intolerance. limitations/degree of comparative enhance activity
coherent complete required or deficit in light of usual baseline and tolerance.
- body malaise desired daily activity. Specific status. provide
noted outcomes: 3. Note client report of information about
- restlessness REFERENCE: The patient will: weakness, fatigue, pain, needed
noted Nurse’s Pocket Guide: 1. participate difficulty accomplishing education/interven
Difficulty in Diagnosis, Prioritized willingly in task. tions regarding
breathing noted Interventions, & necessary/ 4. Ascertain ability to stand quality of life.
- v/s are as Rationales; 11th desired and move about and 3. Symptoms may be
follows: Edition; Doenges et. activities degree of assistance result of/ or
T – 38°C al 2. report necessary/ use of contribute to
P – 84 pp. 874 measurabl equipment. intolerance of
bpm e increase 5. Adjust activities or activity.
R – 30 in activity reduce intensity level or 4. To determine
cpm tolerance. discontinue activity that current status And
cause undesired needs associated
physiological changes. with participation
6. Plan care to carefully in needed/desired
balance rest periods activities.
with activities. 5. To prevent
7. Plan for maximal activity overexertion.
within the positive 6. To reduce fatigue.
attitude client’s ability. 7. Promotes idea of
Encourage client to need for/ normally
maintain positive of progressive
attitude; suggest use of abilities in this
relaxation techniques area.
such as 8. To enhance sense
visualization/guided of well being.
imagery as appropriate.

NURSING CARE PLAN

Cues Nursing Diagnosis Nursing Goal/ Nursing Intervention Rationale Evaluation


S – “Init kanunay Hyperthermia related to
ahung paminaw as disturbances in
patient verbalized. hypothalamic heat
regulating centers
O – febrile with body secondary to infectious
temp of 38°C process.
- Skin warm t touch
Flushed skin Scientific Basis:
-poor skin turgor Hyperthermia (fever) also
- v/s are as follows: occurs naturally as part of
T – 38°C an immune response to
P – 34 bpm infection. In most
R – 30 cpm instances, mild fever from
infection is not harmful
and is thought to be a
defense mechanism. In a
patient with infectious
process, prolonged/severe
hyperthermia is equally
dangerous and should be
controlled.
REFERENCE:
Gulanick, Med et al
Nursing Care Plans
Nursing Daignosis And
Interventions 4th edition;
Mosby Boston US; c 1998
pp.119
Objective
After 8 hours of Independent: After 8 hours of nursing
nursing of nursing 1. Promote surface 1. To lose heat by care intervention the
intervention the cooling by means of radiation and patient will not be able to
patient will be wearing thin/light conduction. get a bed sore.
normothermic with clothes for the 2. To lose heat by
body temp. within patient. radiation and
normal range (36.5 – 2. Perform TSB. conduction.
37.5°C) 3. Keep the 3. To loss heat by
environment well convection.
Specific Outcomes: ventilated. 4. To promote rapid core
1. decrease 4. Encourage patient to body cooling.
core body drink cold water or 5. To reduce metabolic
and skin juices adequately. demands and O2
surface heat. 5. Maintain the patient consumption.
2. Be stabilized bed rest. 6. Hyperventillation may
of body’s 6. Monitor respirations initially be present, but
metabolism. 7. Note ventilatory efforts may
3. Maintain presence/absence of eventually be impaired
Nutritional sweating as body by seizures,
and hydration attempts to increase hypermetabolic state
status. heat loss by (shock and acidosis).
evaporation, 7. Evaporation is
conduction, and decreased by
diffusion. environmental factors
of high humidity and
8. Provide high-calorie
diet high ambient
temperature, as well as
9. Advise for
body factors producing
multivitamin
loss of ability to sweat
supplementation,
especially vitamin C. or sweat gland
dysfunction.
8. To meet increased
metabolic demands.
9. To boost immune
response and
strengthen body,s
immune system.