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ASSESSMENT

NSG DIAGNOSIS

Subjective:
Client indicated pain
was an 8 on a
scale of 0-10. Client
indicated pain was
aching, throbbing
and persistent.
Client indicated
nausea, shielded
eyes with hands,
and appeared
restless.

Acute pain r/t


physical and
biological injury
agents and
advanced disease
process as
evidenced by
facial grimacing
and reports of
pain.

Objective:
Client was
distracted and
answered questions
in brief yes, no
fashion, different
from previous
discussions. Client
presented with
pallor.

PLANNING AND
GOALS
Short Term:
Client will express
relief from pain
within 30 minutes of
medication
administration.
Client will describe
past experiences
with pain and
effectiveness of
methods used to
manage pain,
including
experiences with
side effects.
Client will
communicate a
comfort-function
goal.
Long-term:
Client will function
on acceptable
ability level with
minimal
interference from
pain and medication
side effects.

INTERVENTION
Assess pain
characteristics:
(sharp, constant,
stabbing). Ask
patient regarding
character, location,
or intensity of pain.

Discuss with client


past experiences
with pain and
effectiveness of
medications and
side effects.

RATIONALE
The clients self
report is the single
most reliable
indicator of level of
pain.

Client reported relief


from pain within 30
minutes of
medication
administration.

Systematic, ongoing
assessment and
documentation
provide direction for
the pain treatment
plan (APS, 2003)

Client described
past experiences
with pain,
effectiveness of
treatment methods
and a level at which
she could perform
activities of daily
living.

Provide comfort
measures: back
rubs, position
changes, quiet
music, massage.
Encourage use of
relaxation and/or
breathing exercises.

Non-analgesic
measures can
lessen discomfort
and augment
therapeutic effects
of analgesics.

Monitor vital signs.

Changes in heart
rate or BP may
indicate that patient
is experiencing
pain, especially
when other reasons
for changes in vital
signs have been
ruled out.

Dependent:
Administer
medication as
ordered.

EVALUATION

Each client has a


right to expect
maximum pain
relief. Optimal pain
relief can be

achieved using
analgesics.

PNEUMONIA - inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair gas exchange.
ASSESSMENT
NSG DIAGNOSIS
PLANNING AND
INTERVENTION
RATIONALE
EVALUATION
GOALS
Subjective:
Ineffective Airway
After 8 hours of
Assess the rate and
Tachypnea, shallow
After 8 hours of NI
Hirap akong
Clearance r/t
nursing
depth of
respirations, and
patient was able to
huminga
tracheal bronchial
intervention, patient
respirations and
asymmetric chest
identify/demonstrat
inflammation,
will display patent
chest movement.
movement are
e behaviors to
Objective:
edema formation,
airway with breath
Auscultate lung
frequently present
achieve airway
(+)coughing,
increased sputum
sounds clearing,
fields, noting areas
because of
clearance and
increased sputum
production
and absence of
of decreased or
discomfort of
display patent
production, rapid
possibly
dyspnea.
absent airflow and
moving chest wall
airway with breath
shallow breathing,
evidenced by
adventitious breath
and/or fluid in lung.
sounds clearing;
fever, and shortness
changes in rate,
sounds.
Decreased airflow
absence of dyspnea,
of breath
depth of
occurs in areas with
cyanosis.
respirations.
consolidated fluid.
Elevate head of bed,
change position
frequently.

Teach and assist


patient with proper
deep-breathing
exercises and
proper splinting of
chest.
Force fluids to at
least 3000 mL/day
(unless
contraindicated, as
in heart failure).
Administer
medications as
indicated:
mucolytics,

This will promote


chest expansion,
aeration of lung
segments,
mobilization and
expectoration of
secretions.
Deep breathing
exercises facilitate
maximum
expansion of the
lungs and splinting
reduces chest
discomfort.
Fluids, especially
warm liquids, aid in
mobilization and
expectoration of
secretions.
Aids in reduction of
bronchospasm and
mobilization of

expectorants,
bronchodilators,
analgesics.

secretions.

PNEUMONIA - inflammation of the lung parenchyma, associated with alveolar edema and congestion that impair gas exchange.
ASSESSMENT
NSG DIAGNOSIS
PLANNING AND
INTERVENTION
RATIONALE
EVALUATION
GOALS
Subjective:
Impaired Gas
After 8 hours of
Assess respiratory
To acquire baseline
After 8 hours of
Hirap akong
Exchange r/t
nursing
rate, depth, and
data and to aid in
nursing
huminga
altered oxygenintervention, patient
ease. Observe color
medical
intervention, patient
carrying capacity
will demonstrate
of skin, mucous
management.
demonstrated
Objective:
of blood at
improved ventilation
membranes, and
Tachycardia is
improved ventilation
(+)coughing,
cellular level and
and oxygenation of
nailbeds, noting
usually present as a
and oxygenation of
increased sputum
alveolar-capillary
tissues by ABGs
presence of
result of fever
tissues by ABGs
production, rapid
membrane
within patients
peripheral cyanosis.
and/or dehydration
within patients
shallow breathing,
changes possibly
acceptable range
Monitor heart rate
but may represent a
acceptable range
fever, and shortness
evidenced by
and absence of
and rhythm, and
response to
and absence of
of breath
dyspnea,
symptoms of
body temperature,
hypoxemia.
symptoms of
cyanosis,
respiratory distress.
as indicated.
respiratory distress.
BP 100/60 PR 98
tachycardia,
RR 32 T 38.2
restlessness/chan
Elevate head and
These measures
ges in mentation
encourage frequent
promote maximum
or hypoxia
position changes,
chest expansion,
deep breathing, and
mobilize secretions
effective coughing.
and improve
ventilation.
Maintain bedrest as
ordered. Encourage
use of relaxation
Prevents over
techniques and
exhaustion and
diversional
reduces oxygen
activities.
demands to
facilitate resolution
Monitor ABGs, pulse
of infection.
oximetry.
Follows progress of
disease process and
facilitates
Administer oxygen
alterations in
therapy by
pulmonary therapy.
appropriate means:
nasal prongs, mask,
The purpose of
Venturi mask.
oxygen therapy is to

maintain PaO2
above 60 mmHg.
Oxygen is
administered by the
method that
provides
appropriate delivery
within the patients
tolerance.

ASSESSMENT
Subjective:
Palaging tuyo
lalamunan ko.
Naghihina
pakiramdam ko
Objective:
dry mucous
membranes, poor
skin turgor, delayed
capillary refill
BP 100/60 PR 102
RR 32 T 38.2 fever

NSG DIAGNOSIS
Risk for Deficient
Fluid Volume r/t
excessive fluid loss
(fever, profuse
diaphoresis, mouth
breathing/hyperventil
ation, vomiting) and
decreased oral intake.

PLANNING AND
GOALS
After 8 hours of
nursing
intervention,
patient will
demonstrate fluid
balance evidenced
by individually
appropriate
parameters, e.g.,
moist mucous
membranes, good
skin turgor, prompt
capillary refill,
stable vital signs.

INTERVENTION

RATIONALE

EVALUATION

Assess vital sign


changes: increasing
temperature,
prolonged fever,
orthostatic
hypotension,
tachycardia.

Elevated
temperature and
prolonged fever
increases metabolic
rate and fluid loss
through
evaporation.

After 8 hours of
nursing
intervention,
patient
demonstrated fluid
balance evidenced
by individually
appropriate
parameters, e.g.,
moist mucous
membranes, good
skin turgor, prompt
capillary refill,
stable vital signs.

Assess skin turgor,


moisture of mucous
membranes.
Monitor intake and
output (I&O), noting
color, character of
urine.
Force fluids to at
least 3000 mL/day
or as individually
appropriate.

Administer
medications as
indicated:
antipyretics,
antiemetics.

This is an indirect
indicator of
adequacy of fluid
volume.
Provides
information about
adequacy of fluid
volume and
replacement needs.
Meets basic fluid
needs, reducing risk
of dehydration and
to mobilize
secretions and
promote
expectoration.
To reduce fluid
losses.

Provide
supplemental IV
fluids as necessary.

ASSESSMENT
Subjective:
Palaging tuyo
lalamunan ko.
Naghihina
pakiramdam ko
Objective:
dry mucous
membranes, poor
skin turgor, delayed
capillary refill
BP 100/60 PR 102
RR 32 T 38.2 fever

NSG DIAGNOSIS
Risk for
Imbalanced
Nutrition: Less
Than Body
Requirements r/t
increased
metabolic needs
secondary to
fever and
infectious process
/ anorexia
associated with
bacterial toxins,
the odor and
taste of sputum,
and certain
aerosol
treatments

PLANNING AND
GOALS
After 8 hours of
nursing
intervention, patient
will demonstrate
increased appetite,
and maintain/regain
desired body
weight.

INTERVENTION

RATIONALE

EVALUATION

Identify factors that


are contributing to
nausea or vomiting:
copious sputum,
aerosol treatments,
severe dyspnea,
pain.

Choice of
interventions
depends on the
underlying cause of
the problem.

After 8 hours of
nursing
intervention, patient
demonstrated

Evaluate general
nutritional state,
obtain baseline
weight.

Presence of chronic
conditions (COPD or
alcoholism) or
financial limitations
can contribute to
malnutrition,
lowered resistance
to infection, and/or
delayed response to
therapy.

Assist and
encourage oral
hygiene after
emesis, after
aerosol and postural
drainage
treatments, and
before meals.
Maintain adequate
nutrition to offset
hypermetabolic
state secondary to
infection. Ask the
dietary department

Eliminates noxious
sights, tastes,
smells from the
patient environment
and can reduce
nausea.
To replenish lost
nutrients.

to provide a highcalorie, high-protein


diet consisting of
soft, easy-to-eat
foods as ordered by
MD.
Provide small,
frequent meals,
including dry foods
(toast, crackers)
and/or foods that
are appealing to
patient.

ASSESSMENT
Subjective:
Madali akong
mapagod.
Objective:
+ dyspnea
+ tachypnea
+ pallor/cyanosis
BP 100/60 PR 102
increased RR 32 w T
36

NSG DIAGNOSIS
Activity
intolerance
May be related to
Imbalance
between oxygen
supply and
demand
General
weakness
Exhaustion
associated with
interruption in
usual sleep
pattern because
of discomfort,
excessive
coughing, and
dyspnea
Possibly
evidenced by:
- Verbal reports of
weakness, fatigue,
exhaustion

PLANNING AND
GOALS
After 8 hours of
nursing
intervention, patient
will demonstrate a
measurable
increase in
tolerance to activity
with absence of
dyspnea and
excessive fatigue,
and vital signs
within patients
acceptable range.

These measures
may enhance intake
even though
appetite may be
slow to return.

INTERVENTION

RATIONALE

EVALUATION

Determine patients
response to activity.
Note reports of
dyspnea, increased
weakness and
fatigue, changes in
vital signs during
and after activities.

Establishes patients
capabilities and
needs and
facilitates choice of
interventions.

Provide a quiet
environment and
limit visitors during
acute phase as
indicated.

Reduces stress and


excess stimulation,
promoting rest.

After 8 hours of
nursing
intervention, patient
demonstrated
measurable
increase in
tolerance to activity
with absence of
dyspnea and
excessive fatigue,
and vital signs
within patients
acceptable range.

Explain importance
of rest in treatment
plan and necessity
for balancing
activities with rest.

Bedrest is
maintained during
acute phase to
decrease metabolic
demands, thus
conserving energy
for healing.

Assist with self-care


activities as
necessary. Provide
for progressive

Minimizes
exhaustion and
helps balance
oxygen supply and

- Exertional
dyspnea, tachypnea
- Tachycardia in
response to activity
Development/worse
ning of
pallor/cyanosis

increase in activities
during recovery
phase and demand.

demand.

ASSESSMENT
Subjective:
Kaninang umaga
lang ako
naoperahan
Objective:
Weak looking
(+) wound
BP 100/60 PR 102
RR 32 T 38.2 fever

NSG DIAGNOSIS
Risk for [Spread]
of Infection r/t
inadequate
primary and
secondary
defenses (i.e.
immunosuppressio
n)

PLANNING AND
GOALS
After 8 hours of
nursing
intervention, patient
will identify
interventions to
prevent/reduce
risk/spread
of/secondary
infection. AND
achieve timely
resolution of current
infection without
complications.

INTERVENTION
Monitor vital signs
closely, especially
during initiation of
therapy.

Fever may indicate


infection. This will
also serve as
baseline.

Demonstrate and
encourage good
hand washing
technique.

Effective means of
reducing spread or
acquisition of
infection.

Institute isolation
precautions as
individually
appropriate.

Isolation techniques
may be desired to
prevent spread from
other infectious
processes.

Encourage
adequate rest
balanced with
moderate activity.
Promote adequate
nutritional intake.

Facilitates healing
process and
enhances natural
resistance.

Administer and
monitor
effectiveness of
antimicrobial
therapy.
ASSESSMENT
Subjective:
Objective:
BP 100/60 PR
102 RR 32 T 38.2
fever

NSG DIAGNOSIS
Deficient Knowledge
regarding condition,
treatment, selfcare, and discharge
needs
R/T Lack of
exposure,
Misinterpretation of
information,
Altered recall

PLANNING AND
GOALS
After 8 hours of
nursing
intervention, patient
will
verbalize
understanding of
condition, disease
process, and
prognosis,
therapeutic regimen
and initiate

RATIONALE

EVALUATION
After 8 hours of
nursing
intervention, patient
identified
interventions to
prevent/reduce
risk/spread
of/secondary
infection. AND
achieve timely
resolution of current
infection without
complications.

Prophylaxis may be
indicated.

INTERVENTION

RATIONALE

EVALUATION

Discuss debilitating
aspects of disease,
length of
convalescence, and
recovery
expectations.
Identify self-care
and homemaker
needs.

Information can
enhance coping and
help reduce anxiety
and excessive
concern.

After 8 hours of
nursing
intervention, patient
demonstrated

Provide information

Fatigue and
depression can
affect ability to

Possibly evidenced by
Requests for
information; statement
of misconception
Failure to
improve/recurrence

necessary lifestyle
changes.

in written and
verbal form.

assimilate
information and
follow therapeutic
regimen.

PANCREATITIS - is the painful inflammatory condition in which the enzymes of the pancreas are prematurely activated resulting in
autodigestion of the pancreas.
Acute Pain r/t Obstruction of pancreatic, biliary ducts; Risk for Infection r/t Inadequate primary defenses; Imbalanced
Nutrition: Less Than Body Requirements r/t Vomiting, decreased oral intake; prescribed dietary restrictions Risk for Fluid
Volume Deficit r/t decreased oral intake
ASSESSMENT
.
PLANNING AND GOALS
INTERVENTION
RATI
EVALUATION
DIAGNOSI
O
S
Subjective:
Acute
After 8 hours of nursing
Investigate verbal reports of pain,
After 8 hours of
Pain r/t
intervention, patient will
noting specific location and
nursing
Objective:
Obstructi
report pain is
intensity (010 scale).
intervention, patient
on of
relieved/controlled, follow
demonstrated
BP 100/60 PR 102
pancreati
prescribed therapeutic
Provide alternative comfort
RR 32 T 38.2 fever
c, biliary
regimen and demonstrate
measures (back rub), encourage
ducts
use of methods that provide
relaxation techniques (guided
relief.
imagery, visualization), quiet
diversional activities (TV, radio).

ASSESSMENT

DIAGNOSIS
Risk for Deficient Fluid
Volume r/t third-space
fluid transudation, ascites
formation

PLANNING AND
GOALS
After 8 hours of
nursing
intervention, patient
will maintain
adequate hydration
as evidenced by
stable vital signs,
good skin turgor,
prompt capillary
refill, strong
peripheral pulses,
and individually
appropriate urinary
output.

Administer analgesics in timely


manner (smaller, more frequent
doses).
INTERVENTION
RATIO
Monitor BP and
measure CVP if
available.

Fluid sequestration
may result in
profound
hypotension.

Measure I&O
including vomiting,
gastric aspirate,
diarrhea. Calculate
24-hr fluid balance.

Indicators of
replacement needs
and effectiveness of
therapy.

Record color and


character of gastric
drainage, measure
pH, and note
presence of occult

Risk of gastric
bleeding and
hemorrhage is high.

EVALUATION
After 8 hours of
nursing
intervention, patient
maintained
adequate hydration
as evidenced by
stable vital signs,
good skin turgor,
prompt capillary
refill, strong
peripheral pulses,
and individually
appropriate urinary
output.

blood.
Weigh as indicated.
Correlate with
calculated fluid
balance.
Note poor skin
turgor, dry skin and
mucous
membranes, reports
of thirst.
Observe and record
peripheral and
dependent edema.
Measure abdominal
girth if ascites
present.
ASSESSMENT
Subjective:
Objective:
BP 100/60 PR 102
RR 32 T 38.2 fever

NSG DIAGNOSIS
Imbalanced
Nutrition: Less
Than Body
Requirements r/t
Vomiting,
decreased oral
intake; prescribed
dietary
restrictions
Possibly
evidenced by
Reported
inadequate food
intake, Aversion
to eating,
reported altered
taste sensation,
lack of interest in
food, Weight loss,
Poor muscle tone

PLANNING AND
GOALS
After 8 hours of
nursing
intervention, patient
will
-Demonstrate
progressive weight
gain toward goal
with normalization
of laboratory values
-Experience no
signs of
malnutrition.
-Demonstrate
behaviors, lifestyle
changes to regain
and/or maintain
appropriate weight.

INTERVENTION

Weight loss may


suggest
hypovolemia.
Further
physiological
indicators of
dehydration.

Edema and fluid


shifts occur as a
result of increased
vascular
permeability.
RATIONALE

Weigh patient.

Baseline

Provide frequent
oral care.

Decreases vomiting
stimulus and
inflammation and
irritation of dry
mucous membranes

Assist patient in
selecting food and
fluids that meet
nutritional needs
and restrictions
when diet is
resumed.
Administer
hyperalimentation
and lipids, if
indicated.

Administer

Compliance

IV administration of
calories, lipids, and
amino acids should
be instituted before
nutrition and
nitrogen depletion is
advanced.
Used in chronic
pancreatitis to
correct deficiencies

EVALUATION
After 8 hours of
nursing
intervention, patient
demonstrated

medications as
indicated:
Replacement
enzymes: Vitamins
ADEK

Monitor serum
glucose and provide
insulin as ordered if
appropriate

to promote
digestion and
absorption of
nutrients.
Indicator of insulin
needs because
hyperglycemia is
frequently present.

OBESITY
Imbalanced Nutrition: More Than Body Requirements r/t food intake that exceeds body needs
Disturbed Body Image r/t Family/subculture view of overeating

Stroke (CVA) ASSESSMENT


Subjective:
Objective:
BP 100/60 PR 102
RR 32 T 38.2 fever

NSG DIAGNOSIS
Ineffective
Cerebral Tissue
Perfusion r/t
Interruption of
blood flow:
occlusive
disorder,
hemorrhage;
cerebral vasospasm, cerebral
edema
Evidenced by:
Altered level of
consciousness;
memory loss,
changes in
motor/sensory
responses;

PLANNING AND
GOALS
After 8 hours of
nursing
intervention, patient
will demonstrate
stable vital signs
and absence of
signs of increased
ICP.
Pt. will maintain
usual/improved
level of
consciousness,
cognition, and
motor/sensory
function and display
no further
deterioration/

INTERVENTION

RATIONALE

EVALUATION

Closely assess and


monitor neurological
status frequently
and compare with
baseline.

Assesses trends in
level of
consciousness (LOC)
and potential for
increased ICP and is
useful in
determining
location, extent, and
progression of
damage.

After 8 hours of
nursing
intervention, patient
demonstrated

Monitor VS: changes


in blood pressure,
compare BP
readings in both
arms.

Evaluate pupils,

Fluctuations in
pressure may occur
because of cerebral
injury in vasomotor
area of the brain.
Pupil reactions are

restlessness

recurrence of
deficits.

noting size, shape,


equality, light
reactivity. Assess
higher functions,
including speech, if
patient is alert.

regulated by the
oculomotor (III)
cranial nerve and
are useful in
determining
whether the brain
stem is intact.

Position with head


slightly elevated
and in neutral
position.

Reduces arterial
pressure by
promoting venous
drainage and may
improve cerebral
perfusion.

Maintain bedrest,
provide quiet and
relaxing
environment, and
restrict visitors and
activities.
Prevent straining at
stool, holding
breath.

Administer
supplemental
oxygen as indicated.
Administer
medications as
indicated (anticoag,
anti platelet,
antihypertensives,
antifibrinolytics,
steroids.)
Prepare for surgery,
as appropriate:
endarterectomy,
microvascular
bypass, cerebral
angioplasty.

Continuous
stimulation or
activity can increase
intracranial pressure
(ICP)
Valsalva maneuver
increases ICP and
potentiates risk of
rebleeding.
Reduces hypoxemia.
May be necessary to
resolve situation,
reduce neurological
symptoms of
recurrent stroke.

ASSESSMENT
Subjective:
Objective:
+ Flexion
extension
withdrawal of
lower extremities
+ weakness of
upper extremities

NSG DIAGNOSIS
Impaired Physical
Mobility r/t
neuromuscular
involvement as
manifested by
extremity weakness,
paresthesia

BP 100/60 PR 102
RR 32 T 38.2 fever

PLANNING AND
GOALS
After 8 hours of
nursing
intervention, patient
will
maintain/increase
strength and
function of affected
or compensatory
body part.
- Maintain optimal
position of function
as evidenced by
absence of
contractures, foot
drop

INTERVENTION
Assess extent of
impairment initially
and on a regular
basis.

For baseline and to


assist in choice of
interventions.

Change positions at
least every 2 hrs
(supine, side lying).

Reduces risk of
tissue injury.

Place pillow under


axilla to abduct arm

Prevents adduction
of shoulder and
flexion of elbow.

Place hard handrolls in the palm


with fingers and
thumb opposed

Hard cones
decrease the
stimulation of finger
flexion, maintaining
finger and thumb in
a functional
position.

Provide egg-crate
mattress, water
bed, flotation
device, or
specialized beds, as
indicated.
Begin active or
passive ROM to all
extremities
(including splinted)
on admission.
ASSESSMENT
Subjective:
Objective:
+ trache
BP 100/60 PR 102
RR 32 T 38.2 fever

NSG DIAGNOSIS
Impaired Verbal
Communication
r/t presence of
trache
As E by: Impaired
articulation; does
not/cannot speak
(dysarthria)

PLANNING AND
GOALS
After 8 hours of
nursing
intervention, patient
will be able to
establish method of
communication in
which needs can be
expressed.

RATIONALE

INTERVENTION

EVALUATION
After 8 hours of
nursing
intervention, patient
maintained/increase
d strength and
function of affected
or compensatory
body part.
Patient maintained
optimal position of
function as
evidenced by
absence of
contractures, foot
drop

Promotes even
weight distribution,
decreasing pressure
on bony points and
decubitus formation
Minimizes muscle
atrophy, promotes
circulation, helps
prevent
contractures.
RATIONALE

Assess extent of
dysfunction: patient
cannot understand
words or has trouble
speaking or making
self understood.

Choice of
interventions
depends on type of
impairment.

Ask patient to follow

Tests for receptive

EVALUATION
After 8 hours of
nursing
intervention, patient
demonstrated

simple commands
(Close and open
your eyes, Raise
your hand)
Ask patient to write
his name and a
short sentence.
Provide a special
call bell that can be
activated by
minimal pressure if
necessary.
Talk directly to
patient, speaking
slowly and distinctly.
Since patient cannot
speak,simplify
questions by
phrasing them to be
answered simply by
yes or no.
Encourage
SO/visitors to persist
in efforts to
communicate with
patient:

Consult and refer


patient to speech
therapist.

aphasia.

Tests for writing


disability (agraphia)
and deficits in
reading
comprehension
Allays anxiety
related to inability
to communicate and
fear that needs will
not be met
promptly.
Reduces confusion
and allays anxiety
at having to process
and respond to
large amount of
information at one
time.
It is important for
family members to
continue talking to
patient to reduce
patients isolation,
promote
establishment of
effective
communication
Assesses individual
verbal capabilities
and sensory, motor,
and cognitive
functioning to
identify
deficits/therapy
needs

Myocardial infarction (MI) or acute myocardial infarction (AMI) commonly known as heart attack happens when there is marked
reduction or loss of blood flow through one or more of the coronary arteries, resulting in cardiac muscle ischemia and necrosis.
ASSESSMENT
NSG DIAGNOSIS
PLANNING AND
INTERVENTION
RATIONALE
EVALUATIO
GOALS
N
Subjective:
Acute Pain r/t
After 8 hours of
Monitor and
Pain is a subjective
After 8
Tissue ischemia
nursing
document
experience and must be
hours of
Objective:
(coronary artery
intervention,
characteristic of
described by patient. BP,
nursing
occlusion)
patient will
pain, noting verbal
HR and RR may be
intervention,
BP 100/60 PR 102
-Verbalize
reports, nonverbal
increased as a result of
patient
RR 32 T 38.2 fever
Possibly evidenced
relief/control of
cues (moaning,
pain.
demonstrate
by
chest pain within
crying, grimacing,
d
appropriate time
restlessness,
Reports of
frame for
diaphoresis,
Decreases external stimuli,
chest pain
administered
clutching of chest)
which may aggravate
with/without
medications.
and BP or heart rate
anxiety and cardiac strain,
radiation
changes.
limit coping abilities and
Facial
adjustment to current
grimacing
Provide
quiet
situation.
Restlessness,
environment,
calm
changes in
activities, and
Helpful in decreasing
level of
comfort
measures.
perception and response to
consciousness
pain.
Changes in
Instruct patient to
pulse, BP
do relaxation
techniques: deep
and slow breathing,
Increases amount of
distraction
oxygen available for
behaviors,
myocardial uptake and
visualization,
thereby may relieve
guided imagery.
discomfort associated with
tissue ischemia.
Administer
supplemental
Hypotension and
oxygen by means of
respiratory depression can
nasal cannula or
occur as a result of narcotic
face mask, as
administration.
indicated.
These would be useful for
pain control by coronary
vasodilating effects, which
Check vital signs
increase coronary blood
before and after
flow and myocardial
narcotic
perfusion.
medication.

ASSESSMENT
Subjective:
Objective:
BP 100/60 PR 102
RR 32 T 38.2 fever

NSG DIAGNOSIS
Activity
Intolerance r/t
Imbalance
between
myocardial oxygen
supply and
demand
Possibly evidenced
by
Alterations in
heart rate
and BP with
activity
Development
of
dysrhythmias
Changes in
skin
color/moistur
e
Exertional
angina
Generalized
weakness

ASSESSMEN
T
Subjective:
Objective:
BP 100/60
PR 102 RR
32 T 38.2
fever

NSG DIAGNOSIS
Risk for
Decreased
Cardiac Output
r/t
infarcted/dyskin
etic muscle,
Changes in
rate, rhythm,
electrical

PLANNING AND
GOALS
After 8 hours of
nursing
intervention,
patient will
demonstrate
measurable/
progressive
increase in
tolerance for
activity with heart
rate/rhythm and BP
within patients
normal limits
-Report absence of
angina with activity.

PLANNING AND
GOALS
After 8 hours of
nursing
intervention,
patient will
maintain
hemodynamic
stability, e.g., BP,
cardiac output
within normal

Administer
medications as
indicated
(Antianginals, Betablockers,
Analgesics,
INTERVENTION
Document heart
rate and rhythm
and changes in BP
before, during, and
after activity.
Encourage rest
periods. Provide
nonstress
diversional
activities.
Instruct patient to
avoid increasing
abdominal pressure
(straining during
defecation).

Facilitate referral to
cardiac
rehabilitation
program if indicated
INTERVENTION
Auscultate BP. Compare
both arms and obtain
lying, sitting, and
standing pressures
when able.
Evaluate quality of
pulses on both pulse
points.

RATIONALE
Trends determine patients
response to activity and
may indicate myocardial
oxygen deprivation
Reduces myocardial
workload and oxygen
consumption, reducing risk
of complications.

EVALUATIO
N
After 8
hours of
nursing
intervention,
patient
demonstrate
d

Activities that require


holding the breath and
bearing down (Valsalva
maneuver) can result in
bradycardia (temporarily
reduced cardiac output)
and rebound tachycardia
with elevated BP.
Provides continued support
and/or additional
supervision and
participation in recovery
and wellness process.

RATIONALE

Hypotension may occur related to


ventricular dysfunction,
hypoperfusion of the myocardium,
and vagal stimulation.
Decreased cardiac output results in
diminished weak or thready pulses.
S3 is usually associated with HF, S4

EVALUATIO
N
After 8
hours of
nursing
intervention,
patient
demonstrate
d

conduction

range, adequate
urinary output,
decreased
frequency/absenc
e of
dysrhythmias.
Report
decreased
episodes of
dyspnea, angina.
Demonstrate
an increase in
activity
tolerance.

Auscultate heart
sounds.

Provide small and


easily digested meals
Have emergency
equipment and/or
medications available.

Administer
supplemental oxygen,
as indicated.
Maintain IV or Hep-Lock
access as indicated.
Monitor laboratory
data: cardiac enzymes,
ABGs, electrolytes and
report to MD as
indicated
Administer
antidysrhythmic drugs
as indicated.

ASSESSMEN
T
Subjective:
Objective:
BP 100/60
PR 102 RR
32 T 38.2

NSG DIAGNOSIS
Risk for
Ineffective
Tissue Perfusion
r/t
Reduction/interr
uption of blood
flow, e.g.,

PLANNING AND
GOALS
After 8 hours of
nursing
intervention,
patient will
demonstrate
adequate
perfusion as

INTERVENTION
Investigate sudden
changes or continued
alterations in
mentation (changes in
LOC, mentation,
stupor).

may be associated with myocardial


ischemia, Presence of murmurs or
friction rubs indicates disturbances of
normal blood flow within the heart:
Large meals may increase
myocardial workload and cause vagal
stimulation, resulting in bradycardia
or ectopic beats
Sudden coronary occlusion, lethal
dysrhythmias, extension of infarct,
and unrelenting pain are situations
that may precipitate cardiac arrest,
requiring immediate life-saving
therapies
Increases amount of oxygen
available for myocardial uptake,
reducing ischemia and resultant
cellular irritation and/or dysrhythmias
Patent line is important for
administration of emergency drugs in
presence of persistent lethal
dysrhythmias or chest pain.
Presence of hypoxia indicates need
for supplemental oxygen. Electrolyte
imbalances: hypokalemia or
hyperkalemia, adversely affects
cardiac rhythm and contractility.
Dysrhythmias are usually treated
symptomatically, except for PVCs,
which are often treated
prophylactically
RATIONALE
Cerebral perfusion is directly
related to cardiac output
Systemic vasoconstriction resulting
from diminished cardiac output
may be evidenced by decreased

EVALUATION
After 8 hours
of nursing
intervention,
patient
demonstrated

fever

vasoconstriction,
hypovolemia/shu
nting, and
thromboembolic
formation

ASSESSMENT
Subjective:
Objective:
BP 100/60 PR 102
RR 32 T 38.2 fever

individually
appropriate, e.g.,
skin warm and
dry, peripheral
pulses
present/strong,
vital signs within
patients normal
range, patient
alert/oriented,
balanced I&O,
absence of
edema, free of
pain/discomfort.

NSG DIAGNOSIS
Risk for Excess
Fluid Volume r/t
Increased
sodium/water
retention

Inspect for pallor,


cyanosis, mottling, cool
and clammy skin. Note
strength of peripheral
pulses.
Monitor laboratory
data: ABGs, BUN,
creatinine, electrolytes,
coagulation studies
(PT, aPTT, clotting
times).

skin perfusion and diminished


pulses.
Indicators of organ perfusion and
function

To reduce risk of thrombophlebitis


or mural thrombus formation.

Administer medications
as indicated:
Antiplatelet,
anticoagulants

PLANNING AND
GOALS
After 8 hours of
nursing
intervention, patient
will ---Maintain fluid
balance as
evidenced by BP
within patients
normal limits.
- Be free of
peripheral/ venous
distension and
dependent edema,
with lungs clear and
weight stable.

INTERVENTION
Auscultate breath
sounds for presence
of crackles.
Measure I&O, noting
decrease in output,
concentrated
appearance

Weigh daily.

Maintain total fluid


intake at 1,500
mL/24 hr (as
ordered by MD)
within
cardiovascular
tolerance.
Administer

RATIONALE
May indicate
pulmonary edema
secondary to
cardiac
decompensation.
Decreased cardiac
output results in
impaired kidney
perfusion, sodium
and water retention,
and reduced urine
output.
Sudden changes in
weight reflect
alterations in fluid
balance.
Meets normal adult
body fluid
requirements, but
may require
alteration or
restriction in
presence of cardiac

EVALUATION
After 8 hours of
nursing
intervention, patient
demonstrated

diuretics:
furosemide (Lasix),
spironolactone with
hydrochlorothiazide
(Aldactazide),
hydralazine
(Apresoline).

decompensation.
May be necessary
to correct fluid
overload. Drug
choice is usually
dependent on acute
or chronic nature of
symptoms.

Congestive Heart Failure (CHF) or heart failure is a condition in which the heart cant pump enough blood to the bodys other organs.
Nursing Care Plans
Fluid Volume Excess
Goals

Body weight will remain within normal limits

Electrolyte levels will be within normal limits

Will demonstrate adequate knowledge concerning medical condition.

Will maintain optimal fluid balance

Will verbalize less dyspnea and be more comfortable.


Interventions

Administer Oxygen as ordered

Assess for symptoms such as dizziness, weakness/fatigue, nausea/vomiting, confusion, sweatiness, cyanosis. Notify physician as
appropriate.

Assess for presence of edema

Check breath sounds and assess for labored breathing.

Check Vital Signs

Keep head of bed elevated

Monitor fluid intake, restrict sodium intake as ordered.

Monitor Lab work; K+, NA, BUN, Creatinine

Observe for signs and symptoms of malnutrition, Do not force resident to eat. Offer small frequent feedings. Assess food preferences.

Weigh patient daily


(Potential for) Decreased cardiac output
Goal

Will maintain optimal cardiac output and vital signs within acceptable limits, no s/sx of decreased cardiac output.
Interventions

Administer medications as ordered by MD and check for side effects.

Assess and document breath sounds such as dyspnea, cough, extended expiration, wheezing.

Assess and document heart sounds, apical heart rate, presence of any abnormal heart sounds.

Check for symptoms related to decreased cardiac output, such as chest pain, dyspnea, orthopnea, dependent edema, JVD, fluid
overload.

Discourage smoking. Discuss avoiding allergens when possible.

Encourage activity as tolerated, rest as needed.

Encourage proper posture (stand/sit upright, elevate head as needed) to optimize air exchange and comfort.
Monitor breathing pattern; include rate, rhythm, depth, pursed lips, nasal flaring, fatigue.
Obtain lab/diagnostic work as ordered and report results to MD.
Potential for fluid volume overload.
Goals:

Will be free from s/sx or complications related to fluid overload.


Interventions:

Administer diuretics as ordered and monitor for side effects.

Encourage adequate fluid intake within fluid restrictions as ordered by MD

Ensure that snacks and beverages offered at activities comply with all ordered diet and fluid restrictions.

Monitor fluid intake and record

Monitor for s/sx of fluid overload (edema, shortness of breath, dyspnea, jugular vein distention, bounding pulses) and report to MD
Episodes of dyspnea
Goal(s)

Episodes of dyspnea will decrease to less than [daily/weekly/monthly] by ___


Intervention(s)

Administer oxygen at __ L/min as ordered.

Elevate head of bed as needed to promote comfort

Monitor and report signs of dyspnea

Reduce stress and anxiety as much as possible

Report signs of respiratory distress or infection to MD immediately

Speak to patient in calm, low voice to help reduce anxiety.


Potential for decreased endurance
NDx: Potential for decreased endurance due to decreased cardiac output
Intervention(s)

Allow for periods of rest between activities

Determine factors that contribute to intolerance (ie sleep disturbance)

Encourage patient to conserve energy

If applicable, discourage smoking.

Monitor food intake to ensure that activity is supported.

Monitor vital signs during activities.

Slowly increase activity level. Continue to monitor vitals.

1.
2.
3.
4.

HYPERTENSION
Nursing Priorities
Maintain/enhance cardiovascular functioning.
Prevent complications.
Provide information about disease process/prognosis and treatment regimen.
Support active patient control of condition.
Discharge Goals

1.
2.
3.
4.
5.

BP within acceptable limits for individual.


Cardiovascular and systemic complications prevented/minimized.
Disease process/prognosis and therapeutic regimen understood.
Necessary lifestyle/behavioral changes initiated.
Plan in place to meet needs after discharge.
ASSESSMENT
Subjective:
Objective:
BP 100/60 PR 102
RR 32 T 38.2 fever

NSG DIAGNOSIS
Decreased
Cardiac Output
r/t Increased
vascular
resistance,
vasoconstrictio
n,
Ventricular
hypertrophy/rig
idity

PLANNING AND
GOALS
After 8 hours of
nursing intervention,
patient will

Participate in
activities that
reduce
BP/cardiac
workload.
Maintain BP
within
individually
acceptable
range.
Demonstrate
stable cardiac
rhythm and
rate within
patients
normal
range.
Participate in
activities that
will prevent
stress (stress
management,
balanced
activities and
rest plan).

INTERVENTION
Monitor and record BP.
Measure in both arms
and thighs three
times, 35 min apart
while patient is at
rest, then sitting, then
standing for initial
evaluation. Use
correct cuff size and
accurate technique.
Note presence, quality
of central and
peripheral pulses.
Observe skin color,
moisture,
temperature, and
capillary refill time.

Evaluate client reports


or evidence of
extreme fatigue,
intolerance for
activity, sudden or
progressive weight
gain, swelling of
extremities, and
progressive shortness
of breath.
Provide calm, restful
surroundings,

RATIONALE
Comparison of
pressures provides
a more complete
picture of vascular
involvement or
scope of problem.

Pulses in the legs


and feet may be
diminished,
reflecting effects of
vasoconstriction
Presence of pallor;
cool, moist skin; and
delayed capillary
refill time may be
due to peripheral
vasoconstriction or
reflect cardiac
decompensation
and decreased
output.
To assess for signs
of poor ventricular
function or
impending cardiac
failure.

Helps lessen

EVALUATION
After 8 hours of
nursing
intervention, patient
demonstrated

minimize
environmental activity
and noise.
Maintain activity
restrictions (bedrest
or chair rest);
schedule periods of
uninterrupted rest;
assist patient with
self-care activities as
needed.
Instruct in relaxation
techniques, guided
imagery, distractions.
Monitor response to
medications to control
blood pressure.
Administer
medications as
indicated (usually
consisting of several
drugs, including
diuretics, angiotensinconverting enzyme
[ACE] inhibitors,
vascular smooth
muscle relaxants,
beta and calcium
channel blockers).

sympathetic
stimulation;
promotes
relaxation.
Lessens physical
stress and tension
that affect blood
pressure and the
course of
hypertension.

Can reduce stressful


stimuli, produce
calming effect,
thereby reducing BP.
Response to drug
therapy is
dependent on both
the individual as
well as the
synergistic effects
of the drugs

HYPERTENSION:
Activity Intolerance r/t imbalance between oxygen supply and demand as evidenced by Abnormal heart rate or BP response to activity
Desired Outcomes

Participate in necessary/desired activities.

Use identified techniques to enhance activity tolerance.

Report a measurable increase in activity tolerance.

Demonstrate a decrease in physiological signs of intolerance.


3. Acute Pain
Nursing Diagnosis
Pain, acute, headache

May be related to
Increased cerebral vascular pressure
Possibly evidenced by
Verbal reports of throbbing pain located in suboccipital region, present on awakening and disappearing spontaneously after being up
and about
Reluctance to move head, rubbing head, avoidance of bright lights and noise, wrinkled brow, clenched fists
Changes in appetite
Reports of stiffness of neck, dizziness, blurred vision, nausea, and vomiting
Desired Outcomes
Report pain/discomfort is relieved/controlled.
Verbalize methods that provide relief.
Follow prescribed pharmacological regimen.
Demonstrate use of relaxation skills and diversional activities, as indicated, for individual situation.
4. Ineffective Coping
Nursing Diagnosis
Coping, ineffective
May be related to
Situational/maturational crisis; multiple life changes
Inadequate relaxation; little or no exercise, work overload
Inadequate support systems
Poor nutrition
Unmet expectations; unrealistic perceptions
Inadequate coping methods
Gender differences in coping strategies
Possibly evidenced by
Verbalization of inability to cope or ask for help
Inability to meet role expectations/basic needs or problem-solve
Destructive behavior toward self; overeating, lack of appetite; excessive smoking/drinking, proneness to alcohol abuse
Chronic fatigue/insomnia; muscular tension; frequent head/neck aches;
chronic worry, irritability, anxiety, emotional tension, depression
Desired Outcomes
Identify ineffective coping behaviors and consequences.
Verbalize awareness of own coping abilities/strengths.
Identify potential stressful situations and steps to avoid/modify them.
Demonstrate the use of effective coping skills/methods.
6. Deficient Knowledge

Nursing Diagnosis
Knowledge, deficient [Learning Need] regarding condition, treatment plan, self-care and discharge needs
May be related to

Lack of knowledge/recall
Information misinterpretation
Cognitive limitation
Denial of diagnosis
Possibly evidenced by
Verbalization of the problem
Request for information
Statement of misconception
Inaccurate follow-through of instructions; inadequate performance of procedures
Inappropriate or exaggerated behaviors, e.g., hostile, agitated, apathetic
Desired Outcomes
Verbalize understanding of disease process and treatment regimen.
Identify drug side effects and possible complications that necessitate medical attention.
Maintain BP within individually acceptable parameters.
Describe reasons for therapeutic actions/treatment regimen.

4 Seizure Disorder Nursing Care Plans


Seizures are physical findings or changes in behavior caused by uncontrolled electrical firing or discharges from the nerve cells of the
cerebral cortex and are characterized by sudden, brief attacks of altered consciousness, motor activity and sensory phenomena. The term
seizure is often used interchangeably with convulsion.
Nursing Priorities
1. Prevent or control seizure activity.
2. Protect patient from injury.
3. Maintain airway or respiratory function.
4. Promote positive self-esteem.
5. Provide information about disease process, prognosis, and treatment needs.
Discharge Goals
1. Seizures activity controlled.
2. Complications or injury prevented.
3. Capable or competent self-image displayed.
4. Disease process or prognosis, therapeutic regimen, and limitations understood.
5. Plan in place to meet needs after discharge.
1. Risk for Trauma or Suffocation
Nursing Diagnosis
Risk for Trauma
Risk for Suffocation
Risk factors may include
Weakness, balancing difficulties; reduced muscle, hand or eye coordination
Poor vision
Reduced sensation
Cognitive limitations or altered consciousness

Loss of large or small muscle coordination


Emotional difficulties
Possibly evidenced by
Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions
are directed at prevention.
Desired Outcomes
Verbalize understanding of factors that contribute to possibility of trauma and or suffocation and take steps to correct situation.
Identify actions or measures to take when seizure activity occurs.
Identify and correct potential risk factors in the environment.
Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.
Modify environment as indicated to enhance safety.
Maintain treatment regimen to control or eliminate seizure activity.
Recognize need for assistance to prevent accidents or injuries.

ASSESSMENT
Subjective:
Objective:
BP 100/60 PR 102
RR 32 T 38.2 fever

NSG DIAGNOSIS
Risk for
Ineffective Airway
Clearance r/t
Neuromuscular
impairment

PLANNING AND
GOALS
After 8 hours of
nursing
intervention, patient
will
- Maintain effective
respiratory pattern
with airway patent
or aspiration
prevented.

INTERVENTION

RATIONALE

EVALUATION

Ensure patient to
empty mouth of
dentures or foreign
objects if aura
occurs and to avoid
chewing gum and
sucking lozenges if
seizures occur
without warning.

Lessens risk of
aspiration or foreign
bodies lodging in
pharynx.

After 8 hours of
nursing
intervention, patient
demonstrated

Maintain in lying
position, flat
surface; turn head
to side during
seizure activity.
Loosen clothing
from neck or chest
and abdominal
areas.

Helps in drainage of
secretions; prevents
tongue from
obstructing airway.
Aids in breathing or
chest expansion.
Reduces risk of
aspiration or
asphyxiation

Suction as needed.
Supervise
supplemental
oxygen or bag
ventilation as
needed postictally.

Get ready for or


assist with
intubation, if
indicated.

May lessen cerebral


hypoxia resulting
from decreased
circulation or
oxygenation
secondary to
vascular spasm
during seizure.
Presence of
prolonged apnea
postictally may
need ventilatory
support.

4. Knowledge Deficit
Nursing Diagnosis
Knowledge Deficit
May be related to
Lack of exposure, unfamiliarity with resources
Information misinterpretation
Lack of recall; cognitive limitation
Possibly evidenced by
Questions, statement of concerns
Increased frequency or lack of control of seizure activity
Lack of follow-through of drug regimen
Desired Outcomes
Verbalize understanding of disorder and various stimuli that may increase potentiate seizure activity.
Participate in learning process.
Exhibit increased interest or assume responsibility for own learning by beginning to look for information and ask questions.
Adhere to prescribed drug regimen.
Identify relationship of signs and symptoms to the disease process and correlate symptoms with causative factors.
Initiate necessary lifestyle or behavior changes as indicated.
Nursing Interventions
Rationale
Ascertain level of knowledge, including anticipatory needs.
To assess readiness to learn
Individual may not be physically, emotionally, or mentally capable at
Determine clients ability or readiness and barriers to learning.
this time.
Review pathology and prognosis of condition and lifelong need for
Provides opportunity to clarify or dispel misconceptions and present
treatments as indicated. Discuss patients particular trigger factors
condition as something that is manageable within a normal lifestyle.
(flashing lights, hyperventilation, loud noises,video games, TV

Nursing Interventions

Rationale

viewing).
Discuss significance of maintaining good general health, (adequate
diet, rest, moderate exercise, and avoidance of exhaustion, alcohol,
caffeine, and stimulant drugs).
Know and instill the importance of good oral hygiene and regular
dental care.
Identify necessity and promote acceptance of actual limitations;
discuss safety measures regarding driving, using mechanical
equipment, climbing ladders, swimming, and hobbies.

Regularity and moderation in activities may aid in reducing or


controlling precipitating factors, enhancing sense of general wellbeing, and strengthening coping ability and self-esteem. Note: Too
little sleep or too much alcohol can precipitate seizure activity in
some people.
Lessens risk of oral infections and gingival hyperplasia.
Lessens risk of injury to self or others, especially if seizures occur
without warning.

Although legal and civil rights of persons with epilepsy have improved
during the past decade, restrictions still exist in some states
pertaining to obtaining a drivers license, sterilization, workers
compensation, and required reportability to state agencies.
Lack of cooperation with medication regimen is a leading cause of
Review medication regimen, necessity of taking drugs as ordered, and seizure breakthrough. Patient needs to know risks of status epilepticus
not discontinuing therapy without physician supervision. Include
resulting from abrupt withdrawal of anticonvulsants. Depending on
directions for missed dose.
the drug dose and frequency, patient may be instructed to take
missed dose if remembered within a predetermined time frame.
Recommend taking drugs with meals, if appropriate.
May reduce incidence of gastric irritation, nausea and vomiting.
Discuss nuisance and adverse side effects of particular drugs
May indicate need for change in dosage or choice of drug therapy.
(drowsiness, fatigue, lethargy, hyperactivity, sleep disturbances,
Promotes involvement and participation in decision-making process
gingival hypertrophy, visual disturbances, nausea and vomiting,
and awareness of potential long-term effects of drug therapy, and
rashes, syncope and ataxia, birth defects, aplastic anemia).
provides opportunity to minimize or prevent complications.
Knowledge of anticonvulsant use reduces risk of prescribing drugs
that may interact, thus altering seizure threshold or therapeutic
effect. For example, phenytoin (Dilantin) potentiates anticoagulant
Provide information about potential drug interactions and necessity of
effect of warfarin (Coumadin), whereas isoniazid (INH) and
notifying other healthcare providers of drug regimen.
chloramphenicol (Chloromycetin) increase the effect of phenytoin
(Dilantin), and some antibiotics (erythromycin) can cause elevation of
serum level of carbamazepine (Tegretol), possibly to toxic levels.
Useful in controlling serial or cluster seizures. Can be administered in
Familiarize proper use of diazepam rectal gel (Diastat) with patient,
any setting and is effective usually within 15 min. May reduce
SO and caregiver as appropriate.
dependence on emergency department visits.
Encourage patient to wear identification tag or bracelet stating the
Expedites treatment and diagnosis in emergency situations.
presence of a seizure disorder.
Stress need for routine follow-up care and laboratory testing as
Therapeutic needs may change and or serious drug side effects
indicated (CBC should be monitored biannually and in presence of
(agranulocytosis or toxicity) may develop.
sore throat or fever, signs of other infection).
Review local laws and restrictions pertaining to persons with epilepsy
and seizure disorder. Encourage awareness but not necessarily
acceptance of these policies.

Diabetes mellitus (DM) is a chronic diseases characterized by insufficient production of insulin in the pancreas or when the body cannot
effectively use the insulin it produces. This leads to an increased concentration of glucose in the bloodstream (hyperglycemia). It is
characterized by disturbances in carbohydrate, protein, and fat metabolism.
Nursing Priorities
1. Restore fluid/electrolyte and acid-base balance.
2. Correct/reverse metabolic abnormalities.
3. Identify/assist with management of underlying cause/disease process.
4. Prevent complications.
5. Provide information about disease process/prognosis, self-care, and treatment needs.
Discharge Goals
1. Homeostasis achieved.
2. Causative/precipitating factors corrected/controlled.
3. Complications prevented/minimized.
4. Disease process/prognosis, self-care needs, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
ASSESSMENT
Subjective:
Objective:
BP 100/60 PR 102
RR 32 T 38.2 fever

NSG
DIAGNOSIS
Risk for
Infection r/t
High glucose
levels,
decreased
leukocyte
function,
alterations in
circulation

PLANNING AND
GOALS
After 8 hours of nursing
intervention, patient will
---identify interventions
to prevent/reduce risk of
infection.
-Demonstrate
techniques, lifestyle
changes to prevent
development of
infection.

INTERVENTION

RATIONALE

Observe for the signs of


infection and inflammation:
fever, flushed appearance,
wound drainage, purulent
sputum, cloudy urine.

Patients with DM
may be admitted
with infection,
which could have
precipitated the
ketoacidotic state.

Teach and promote good


hand hygiene.

Reduces risk of
crosscontamination.

Maintain asepsis during IV


insertion, administration of
medications, and providing
wound or site care. Rotate
IV sites as indicated.
Provide meticulous skin
care: gently massage bony
areas, keep skin dry. Keep
linens dry and wrinkle-free.

Administer antibiotics as
appropriate.

Increased glucose
in the blood
creates an
excellent medium
for bacteria to
thrive.
Peripheral
circulation may be
ineffective or
impaired, placing
the patient at
increased risk for
skin breakdown

EVALUATION
After 8 hours
of nursing
intervention,
patient
demonstrated

and infection.
Early treatment
may help prevent
sepsis.
ASSESSMENT

NSG DIAGNOSIS

Subjective:
Objective:
BP 100/60 PR
102 RR 32 T
38.2 fever

Imbalanced
Nutrition:
Less Than
Body
Requiremen
ts
r/t insulin
deficiency
Possibly
evidenced by
Increased
urinary output,
dilute urine
Reported
inadequate food
intake, lack of
interest in food
Recent weight
loss; weakness,
fatigue, poor
muscle tone
Diarrhea
Increased
ketones (end
product of fat
metabolism)

PLANNING AND
GOALS
After 8 hours of
nursing
intervention, patient
will Ingest
appropriate
amounts of
calories/nutrients.
Display usual
energy level.
Long term:
Demonstrate
stabilized weight or
gain toward
usual/desired range
with normal
laboratory values.

INTERVENTION

RATIONALE

. Weigh daily or as ordered.

Weighing serves as an
assessment tool to
determine the adequacy
of nutritional intake.

Provide liquids containing


nutrients and electrolytes as
soon as patient can tolerate
oral fluids then progress to a
more solid food as tolerated.

Oral route is preferred


when patient is alert and
bowel function is
restored.

Identify food preferences,


including ethnic and cultural
needs.
Include SO in meal planning as
indicated.

Observe for signs of


hypoglycemia: changes in LOC,
cold and clammy skin, rapid
pulse, hunger, irritability,
anxiety, headache,
lightheadedness, shakiness.
Perform fingerstick glucose
testing.
Administer regular insulin by
intermittent or continuous IV
method as ordered

If patients food
preferences can be
incorporated into the
meal plan, cooperation
with dietary requirements
may be facilitated after
discharge.
To promote sense of
involvement and provide
information to the SO to
understand the
nutritional needs of the
patient.
Hypoglycemia can occur
once blood glucose level
is reduced and
carbohydrate metabolism
resumes and insulin is
being given.
Regular insulin has a
rapid onset and thus
quickly helps move
glucose into cells. Many
believe the continuous
method is the optimal

EVALU
ATION
After 8
hours of
nursing
interven
tion,
patient
Ingeste
d
appropr
iate
amount
s of
calories
/nutrien
ts.
Display
usual
energy
level.

Administer other medications


as indicated: metoclopramide
(Reglan); tetracycline

ASSESSMENT
Subjective:
Lagi ako umiihi
Objective:
Weak thready
pulse, poor skin
turgor, slow
capillary refill
BP 90/60 PR 102
RR 32 T 38.2 fever

NSG
DIAGNOSIS
Deficient
Fluid Volume
r/t osmotic
diuresis as
evidenced by
Increased
urinary
output, dilute
urine

PLANNING AND
GOALS
After 8 hours of nursing
intervention, patient will
--Demonstrate adequate
hydration as evidenced
by stable vital signs,
palpable peripheral
pulses, good skin turgor
and capillary refill,
individually appropriate
urinary output, and
electrolyte levels within
normal range.

INTERVENTION

way to facilitate
transition to
carbohydrate metabolism
and reduce incidence of
hypoglycemia.
May be useful in treating
symptoms related to
autonomic neuropathies
affecting GI tract, thus
enhancing oral intake and
absorption of nutrients.
RATIONALE

Assess patients history


related to duration or
intensity of symptoms such
as vomiting, excessive
urination.

Assists in
estimation of total
volume depletion.

Note orthostatic BP
changes.

Hypovolemia may
be manifested by
hypotension and
tachycardia.

Assess Respiratory pattern:


Kussmauls respirations,
acetone breath.
Assess temperature, skin
color, moisture, and turgor.
Assess peripheral pulses,
capillary refill, and mucous
membranes.

Monitor I&O and note urine


specific gravity.

Acetone breath is
due to breakdown
of acetoacetic acid
and should
diminish as ketosis
is corrected.
Although fever,
chills, and
diaphoresis are
common with
infectious process,
fever with flushed,
dry skin and
decreased skin
turgor may reflect
dehydration.
Provides ongoing
estimate of volume

EVALUATION
After 8 hours
of nursing
intervention,
patient
demonstrated

Weigh daily.

Maintain fluid intake of at


least 2500 mL/day within
cardiac tolerance when oral
intake is resumed.

replacement
needs, kidney
function, and
effectiveness of
therapy.
Provides the best
assessment of
current fluid status
and adequacy of
fluid replacement
Maintains
hydration and
circulating volume

Insert and maintain


indwelling urinary catheter.
Provides for
accurate ongoing
measurement of
urinary output,
especially if
autonomic
neuropathies result
in neurogenic
bladder (urinary
retention/overflow
incontinence)

6. Fatigue
Nursing Diagnosis

Fatigue

May be related to

Decreased metabolic energy production


Altered body chemistry: insufficient insulin
Increased energy demands: hypermetabolic state/infection

Possibly evidenced by

Overwhelming lack of energy, inability to maintain usual routines, decreased performance, accident-prone
Impaired ability to concentrate, listlessness, disinterest in surroundings

Desired Outcomes

Verbalize increase in energy level.


Display improved ability to participate in desired activities.

Nursing Interventions
Discuss with patient the need for activity. Plan schedule with patient
and identify activities that lead to fatigue.
Alternate activity with periods of rest and uninterrupted sleep.
Monitor pulse, respiratory rate, and BP before and after activity.
Discuss ways of conserving energy while bathing, transferring, and so
on.
Increase patient participation in ADLs as tolerated.

Rationale
Education may provide motivation to increase activity level even
though patient may feel too weak initially.
To prevent excessive fatigue.
Indicates physiological levels of tolerance.
Patient will be able to accomplish more with a decreased expenditure
of energy.
Increases confidence level, self-esteem and tolerance level.

10. Risk for Infection


Risks for infection is an increased probability of invasion of pathogenic organisms for a patient with DM. Clients with diabetes are susceptible to
infections because of polymorphonuclear leukocyte function, diabetic neuropathies, and vascular insufficiency as a result is a poor glycemic control;
thus making a wound to heal slowly because the damaged of the vascular system cannot carry sufficient oxygen, WBC, nutrients, and antibodies to
the injured site. Thereby infections increase and enhance possibility of further complications.
Nursing Diagnosis

Risk for Infection

Risk factors

Chronic hyperglycemia
Neurogenic bladder
Peripheral vascular disease

Possibly evidenced by

[Not applicable for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and
nursing interventions are directed at prevention.]

Desired outcomes

Patient will be free of infections as evidenced by normothermia, negative cultures, and WBC within normal levels.
Nursing Interventions
Rationale
Assess temperature every four (4) hours. Notify physician if fever
Fever is a sign of an infection Infection is the most common cause of
occurs.
diabetic ketoacidosis (DKA).
Monitor for signs of infection (e.g., fever, rhonchi, dyspnea, and/or
These are indicators of pneumonia which is common among patients
cough).
with DM.
Assess for dysuria, tachycardia, diaphoresis, nausea, vomiting, and
These are indicators of UTI. Neurogenic bladder predisposes to UTI.
abdominal pain.
Assess for erythema, swelling, and purulent drainage at IV sites.
These are signs of IV catheter infections.
CRF
Chronic renal failure (CRF) or chronic kidney disease (CKD) is the end result of a gradual, progressive loss of kidney function. The loss
of function may be so slow that you do not have symptoms until your kidneys have almost stopped working.

The final stage of chronic kidney disease is called end-stage renal disease (ESRD). At this stage, the kidneys are no longer able to remove
enough wastes and excess fluids from the body. At this point, you would need dialysis or a kidney transplant.
ASSESSMENT
Subjective:
Objective:
BP 100/60 PR 102
RR 32 T 38.2 fever

NSG
DIAGNOSIS
Risk for
Decreased
Cardiac
Output r/t
Fluid
imbalances
affecting
circulating
volume

PLANNING AND
GOALS
After 8 hours of nursing
intervention, patient will
maintain cardiac output
as evidenced by BP and
heart rate within
patients normal range;
peripheral pulses strong
and equal with prompt
capillary refill time.

INTERVENTION

RATIONALE

EVALUATION

Auscultate heart and lung


sounds. Evaluate presence
of peripheral edema,
vascular congestion and
reports of dyspnea.

S3 and S4 heart
sounds with
muffled tones,
tachycardia,
irregular heart rate,
tachypnea,
dyspnea, crackles,
wheezes,edema
and jugular
distension suggest
HF.

After 8 hours
of nursing
intervention,
patient
demonstrated

Assess presence and


degree of hypertension:
monitor BP; note postural
changes (sitting, lying,
standing).
Monitor laboratory and
diagnostic studies:
Electrolytes (potassium,
sodium, calcium,
magnesium), BUN and Cr;
Administer
antihypertensive
drugs such as prazosin
(Minipress), captopril
(Capoten), clonidine
(Catapres), hydralazine
(Apresoline).

Prepare for dialysis as


ordered

Significant
hypertension can
occur because of
disturbances in the
renin-angiotensinaldosterone system
Imbalances can
alter electrical
conduction and
cardiac function.
Reduces systemic
vascular resistance
and renin release
to decrease
myocardial
workload and aid in
prevention of HF
and MI.
For Reduction of
uremic toxins and
correction of
electrolyte
imbalances and
fluid overload

MS
ASSESSMENT
Subjective:
Objective:
BP 100/60 PR 102
RR 32 T 38.2 fever

NSG
DIAGNOSIS
Impaired
Urinary
Elimination r/t
Neuromuscula
r impairment
(spinal cord
lesions/neuro
genic
bladder)

PLANNING AND
GOALS
After 8 hours of nursing
intervention, patient will
be able to

Possibly
evidenced by

Incontinence;
nocturia;
frequency
Retention
with overflow
Recurrent
UTIs

Verbalize
understanding of
condition.
Demonstrate
behaviors/techniqu
es to
prevent/minimize
infection.
Empty bladder
completely and
regularly
(voluntarily or by
catheter as
appropriate).
Be free of urine
leakage.

INTERVENTION

RATIONALE

EVALUATION

Note reports of urinary


frequency, urgency,
burning, incontinence,
nocturia, and size or force
of urinary stream.

Provides
information about
degree of
interference with
elimination or may
indicate bladder
infection.

After 8 hours
of nursing
intervention,
patient
demonstrated

Review drug regimen,


including prescribed, overthe-counter (OTC), and
street.

A number of
medications such
as some
antispasmodics,
antidepressants,
and narcotic
analgesics may
interfere with
bladder emptying.

Institute bladder training


program or timed voidings
as appropriate.

Encourage adequate fluid


intake, avoiding caffeine
and use of aspartame, and
limiting intake during late
evening and at bedtime.

Recommend good hand


washing and proper
perineal care.
Refer to urinary continence
specialist as indicated.

Helps restore
adequate bladder
functioning;
lessens occurrence
of incontinence
and bladder
infection.
Sufficient hydration
promotes urinary
output and aids in
preventing
infection.
Aspartame, a sugar
substitute (e.g.,
Nutrasweet), may
cause bladder
irritation leading to
bladder
dysfunction.
Reduces skin
irritation and risk of
ascending

infection.

Administer medications
as indicated: Oxybutynin
(Ditropan), propantheline
(Pro-Banthine),
hyoscyamine sulfate
(Cytospaz-M), flavoxate
hydrochloride (Urispas),
tolterodine (Detrol).
Catheterize as indicated.

Helpful for
developing
individual plan of
care to meet
patients specific
needs using the
latest techniques,
continence
products.
Reduce bladder
spasticity and
associated
symptoms of
frequency,
urgency,
incontinence,
nocturia.
May be necessary
as a treatment and
for evaluation if
patient is unable to
empty bladder or
retains urine.

Here are 13 nursing care plans for patients with Alzheimers Disease.

1. Disturbed Thought Process


May be related to

Alzheimers Disease
Changes in cognitive abilities
Impaired memory
Disorientation
Chemical imbalances in the brain

Dementia
Neuronal destruction in the brain

Possibly evidenced by

Disorientation to time, place,


person, and circumstance

Decreased ability to reason or


conceptualize

Inability to reason

Inability to calculate

Memory loss

Decreased attention span

Easy distractibility

Inability to follow simple or


complex commands

Deterioration in personal care and


appearance

Dysarthria

Dysphagia

Convulsions

Inappropriate social behavior

Paranoia

Combativeness

Inability to cooperate

Wandering

Disturbance in judgement and


abstract thoughts

Explosive behavior

Illusions, delusions, hallucinations

Deterioration of intellect

Loss of sexual drive and desire,


reduced control of sexual behavior

Inappropriate behavior

Lack of inhibitions

Hypervigilance or hypovigilance

Alteration in sleep pattern

Lethargy

Egocentricity

Desired Outcomes

Patient will have appropriate maintenance of mental and psychological function as long as possible, and reversal of behaviors when
possible.

Family members will be able to exhibits understanding of required care and will demonstrate appropriate coping skills and ability to
utilize community resources.

Patient will achieve functional ability at his optimum level with modifications and alterations within his environment to compensate for
deficits.

Patient will have improved thought processing or will be maintained at a baseline level.

Patient will be aware and oriented if possible, and reality will be maintain at an optimal level.

Patients will have behavioral problems identified and controlled.

Patients family will be able to access community resources and make informed choices regarding patients care, both currently and for
future care.
ASSESSMENT

NSG
DIAGNOSIS

Subjective:
Objective:

PLANNING AND
GOALS
After 8 hours of nursing
intervention, patient will
---

INTERVENTION

RATIONALE

After 8 hours
of nursing
intervention,
patient
demonstrated

BP 100/60 PR 102
RR 32 T 38.2 fever
ASSESSMENT
Subjective:
Objective:
BP 100/60 PR 102

NSG
DIAGNOSIS

PLANNING AND
GOALS
After 8 hours of nursing
intervention, patient will
---

INTERVENTION
.

EVALUATION

RATIONALE

EVALUATION
After 8 hours
of nursing
intervention,
patient

RR 32 T 38.2 fever

demonstrated