Date/ NURSING GOALS AND

CUES INTERVENTION RATIONALE EVALUATION

Time DIAGNOSIS OBJECTIVES

Subjective: Imbalance SHORT TERM: Independent: SHORT TERM:

“Dili man gud sad Nutrition: less After 4hrs of nursing 1. Explain to the 1. It will give a better After 4hrs of nursing
10/24/19 kaayo siya pala than body intervention the patient and understanding on the intervention the
AM inom ug tubig requirements patient or the significant others need of meeting the patient or the patient’s
SHIFT ma’am oy” As related to loss of patient’s watcher will: the importance of daily nutritional watcher was able to:
evidenced by the appetite as  Regain and maintaining proper requirements of the  Regain and
mother. evidenced by increase nutrition. body. increase
decreased fluid appetite appetite
Objective: intake (50ml)  Increase fluid  Increase fluid
 Patient intake and 2. Encourage 2. It will enhance the intake and
refuses to maintain fluid patient to have appetite and will have maintain fluid
eat balance small, frequent better digestion of balance
 Thin Scientific Basis feedings food intake
 Pallor Intake of nutrients LONG TERM: LONG TERM:
 Weakness insufficient to After 3 days of After 3 days of nursing
 Intake: meet metabolic nursing intervention 3. Measure intake 3. To help evaluate intervention the client
50ml needs. the client will: and output of the patient’s fluid balance was able to:
Output:  Demonstrate patient  Demonstrate
40ml progressive progressive
 Decrease weight gain 4. Encourage 4. To maintain weight gain
d weight Reference: toward goal. patient’s watcher to hydration toward goal.
from Nurse’s Pocket increase fluid  Maintain
27.5kg to Guide, Marilynn  Maintain intake balanced
24kg E. Doenges balanced nutrition
(2016, pp. 578- nutrition 5. Encourage to 5. To stimulate
584) choose foods that appetite GOAL MET.
seem appealing.

6. Discuss with the 6. To prevent or limit

watcher the risk fluid imbalance and
factors or potential complications.
problems and
specific
interventions.

Dependent
1. Administer
pharmaceutical
agents as 1. To correct
indicated: electrolyte
* Digestive imbalances and
drugs/enzymes provide additional
nutrition supplement.
* Vitamin/mineral
(iron) supplements
* Medications (e.g.,
antacids,
anticholinergics,
antiemetics,
antidiarrheal)

Collaborative
1. Refer to a 1. It will determine
dietician if needed the exact nutritional
content needed by
the patient and to
solve any present
nutritional problems.
 NURSING CARE PLAN
Name: Patient E. Date of Admission: 10/20/19 Room:
Age: 2 yrs old Sex: Male Chief Complaint: Fever
Religion: Catholic Attending Physician: Dr. Yangson

Date/ NURSING GOALS AND

CUES INTERVENTION RATIONALE EVALUATION
Time DIAGNOSIS OBJECTIVES

Subjective: Hyperthermia Short Term Independent: 1. Vital signs provide Short Term
“init kaayo akong related to After 1 hour of 1. Monitor vital more accurate After 1 hour of
indication of core
10/24/19 anak maong gipa increased appropriate nursing signs. appropriate nursing
temperature.
AM admit nako” as metabolic rate as intervention the intervention the
SHIFT verbalized by the evidence by patient’s temperature patient’s temperature
mother. increased will decrease to 37.5. 2. Provide tepid 2. TSB helps in decreases to 37.5.
Objective: bacteria in urine. sponge bath. lowering the body
VS: Long Term temperature. Long Term
After 4 hours of After 4 hours of
T: 38.9 C
appropriate nursing 3. Remove excess 3. · These decrease appropriate nursing
P: 96 bp intervention the clothing and warmth and increase intervention the
patient’s vital signs covers. evaporative cooling. patient’s vital signs
R: 25 cpm
will return to normal return to normal
BP: 100/60 range; with a 4. Promote a well- 4. To promote clear range; with a
temperature of 36.5 ventilated area to flow of air in the temperature of 36.5-
C,pulse rate of 60- patient. patient’s area. One 37.5,pulse rate of 60-
 Flushed 100 bpm and way of promoting 100 bpm and
skin Scientific Basis respiratory rate of 20- heat loss. respiratory rate of 20-
 Warm to Pyrogens cause a 30 cycles per min. 30 cycles per min.
touch rise in body 5. Advise patient 5. Additional fluids
 Restlessn temperature, it to increase oral help prevent elevated GOAL MET.
ess also acts as an fluid intake. temperature
 Increased antigen triggering associated with
bacteria in immune system dehydration.
urine responses. The

 Weakness hypothalamus 6. Maintain bed 6. Reduce metabolic

reacts to raise the rest. demands/ oxygen
set point and the consumption
body respond by
producing heat. 7. Provide high- 7· To meet increased
calorie diet. metabolic demands.

8. Educate and 8. Teaching the

advise support Support system the
Reference:
system (relative) to right way to do TSB
Nurse’s Pocket
do TSB when will help in knowing
Guide, Marilynn
patient feels hot. what to do in case
E. Doenges
- Luke warm water the patient’s
(2016, pp. 578-
only.
584)
- Make sure that temperature
armpits and groins increases.
were included in
doing TSB.

9. Monitored VS
9. To know the
and recheck.
effectiveness of
nursing interventions
done and to know the
progress of patient’s
condition.

Dependent:

1. Administer 1. Antipyretic
antipyretics, medications lower
orally/rectall body temperature
y (e.g.,
aspirin,
acetaminop
hen), as
ordered.
2. Administer 2. To support
replacement
fluids and circulating volume
electrolytes and tissue perfusion
 Date/ NURSING GOALS AND
CUES INTERVENTION RATIONALE EVALUATION
Time DIAGNOSIS OBJECTIVES

Subjective: Activity Short term: Independent . Short term:

“Maglisod lang intolerance After 3-4 hours of 1. Monitor vital sign 1. Cardiopulmonary After 3-4 hours of
10/24/19 siyag lihok ky related to nursing intervention (Blood Pressure, manifestations result nursing intervention
AM luya kaayo siya generalized patient will use pulse, and from attempts by the patient used identified
SHIFT run.” As weakness identified techniques respirations) during heart and lungs to techniques to enhance
verbalized by the to enhance activity and after activity. supply adequate activity tolerance.
mother. tolerance. amounts of oxygen to
the tissues. Long term:
Objective:
Long term: After 2-3 days of
The patient
After 2-3 days of 2. Assess patient 2. Influences choice nursing intervention
manifested: Scientific Basis
nursing intervention ability to perform of interventions and patient free from
 Weakness A state in which a
patient will able to ADLs (Activities of needed assistance. weakness and risk for
 Fatigue person has
free from weakness daily living) complication been
 Poor insufficient
and risk for prevented.
appetite physical or
complication been 3. Ascertain the 3. To determine
 Restlessn psychological
prevented. client’s ability to current status and GOAL MET.
ess energy to endure
stand and move needs associated
or perform
about and the with participation in
VS: desired physical
degree of needed/activities.
T: 38.9 activities.
assistance
P: 80 bpm
R: 25 cycles per Reference: necessary or use of
minute Nurse’s Pocket equipment
BP: 100/ Guide, Marilynn 4. Although help may
63 mmHg E. Doenges 4. Provide or be necessary, self-
(2016, pp. 578- recommend esteem is enhanced
584) assistance with when client does
activities and some things for self.
ambulation as
necessary, allowing
client to be an
active participant
as much as
possible.
Suggest client
change position
slowly; monitor for
dizziness.

5. Instruct client to 5. Cellular ischemia

stop activity if potentiates risk of
palpitations, chest infarction, and
pain, shortness of excessive
breath, weakness, cardiopulmonary
or dizziness occur. strain and stress may
 lead to
decompensation and
failure.
Collaborative:
1. Provide referral 1. To develop
to other disciplines, individually
such as exercise appropriate
physiologist, therapeutic regimens.
psychological
counseling/therapy,
occupational
therapists, as
indicated.