VIII.

PLANNING
A. NURSING CARE PLAN
Date/Shift Assessment Needs Nursing
Diagnosis
Objective of
care
Nursing Intervention Evaluation
July 23,
2013
7/3
S:
Maglisod ko
ug ginhawa
as verbalized.

O:
-Pale
conjunctiva
-With O2 @
4LPM via
nasal cannula

-Pale and dry
P
H
Y
S
I
O
L
O
G
I
C


Decreased
cardiac
output
related to
increased
vascular
resistance
Rationale:
CAD
causes
narrowing
of blood
vessels.
After 8 hours of
nursing care,
patients cardiac
output will be
improved, as
evidenced by:
-Restlessness
will not be
noted
- Increased
peripheral
pulses
- Pulse rate
Independent
1. Assessed patients
condition To
determine possible
problems
(nurseslabs.com.
July 27, 2014)
2. Monitored and
record vital signs.
For baseline data
(nurseslabs.com.
July 27, 2014)
After 8 hours of Nursing
care, goal not met as
evidenced by:
- Maglisod gihapon ko
gamay ug ginhawa, as
verbalized.
-Restlessness
-Decreased
peripheral pulses
- Decreased Pulse rate
of 50 beats per minute

55

lips
- Restlessness
- Decreased
peripheral
pulses
- Decreased
Pulse Rate
VS:
BP-120/90
mmHg
RR-20 bpm
PR-42 cpm
T-38C
N
E
E
D

Oxyge
nation
This
condition
leads to
intense
pressure
exerted on
the walls of
the blood
vessels.
The bodys
compensat
ory
mechanis
m is to
increase
the
within normal
range
3. Encouraged
patient to verbalize
concerns. To make
client express his
feelings
(nurseslabs.com.
July 27, 2014)
4. Encouraged
patient to change
position every two
hours. To improve
venous return
(nurseslabs.com.
July 27, 2014)
5. Reinforced low
salt and low fat diet.
56

workload
of the heart
and thus
the patient
has
decreased
cardiac
output.
(Nurses
labs.com.
July 27,
2014)
To prevent further
complications of the
disease
(nurseslabs.com.
July 27, 2014)
6. Encouraged
patient to do
relaxation
techniques. To
reduce stress
(nurseslabs.com.
July 27, 2014)
7. Encouraged
patient to engage in
diversional activities
such as chatting with
57

family and friends.
To divert attention
and help patient
lessen experienced
pain and anxiety
(nurseslabs.com.
July 27, 2014)
Dependent
8. Administered
medications as
prescribed. To
help relieve the signs
and symptoms
experienced by the
patient
(nurseslabs.com.
58

July 27, 2014)
Collaborative
9. Instructed the
watcher or any
member of the family
to lessen foods high
in salt and fat in his
diet. To prevent
further complications
(nurseslabs.com.
July 27, 2014)
10. Advised the
watcher to stay and
talk with the patient.
To help lessen the
pain and anxiety that
59

the patient is
currently feeling.
(nurseslabs.com.
July 27, 2014)











60

Date/Shift Assessment Needs Nursing
Diagnosis
Objective of
care
Nursing Intervention Evaluation
July 23,
2013
7/3
S:
Maglisod ko
ug ginhawa.
Punga kaayo
as verbalized.
Luya kaayo
akong lawas.
Kapoy ilihok,
as verbalized.

O:
-Pale
palpebral
conjunctiva
P
H
Y
S
I
O
L
O
G
I
C


N
Ineffective
tissue
perfusion r/t
Decreased
hemoglobin
concentration
in blood
The
oxygen
content of
arterial blood
is almost all
bound to hgb.
The blood
After 8 hours
of nursing
care, patient
will be able to
demonstrate
behaviors on
how to have
effective
airways, as
evidenced by:
- (-) Pale
palpebral
conjunctiva
- (-) Pale and
Independent
1. Established rapport
To gain trust and
cooperation To
determine possible
problems
(nurseslabs.com. July
27, 2014).
2. Assessed patients
condition To
determine possible
problems
(nurseslabs.com. July
27, 2014)
After 8 hours of
Nursing care, goal
partially met as
evidenced by:
- Punga gihapon,
as verbalized.
- (+) Pale palpebral
conjunctiva
- (+) Pale and dry lips
-(+) Shortness of
breath
- (-) Restlessness
-Decreased
peripheral pulses
61

-With O2 @
4LPM via
nasal cannula
-Pale and dry
lips
-Shortness of
breath
- Restlessness
- Decreased
peripheral
pulses
- Decreased
Pulse Rate
VS:
BP-120/90
mmHg
E
E
D

Oxyge
nation
vessels
cannot
adequately
produce
erythropoietin
that leads to
decrease in
Hgb and Hct
count, thus
resulting to
anemia.
Because of
this, the
patient
manifested
pale
dry lips
-Shortness of
breath not
noted
- Restlessness
not noted
- Increased
peripheral
pulses
- Pulse Rate
within normal
range
3. Monitored and record
vital signs. For
baseline data
(nurseslabs.com. July
27, 2014)
4. Encourage quiet and
restful atmosphere.
To conserve energy
and lower tissue
oxygen demands To
determine possible
problems
(nurseslabs.com. July
27, 2014)
5. Encouraged early
ambulation once
- Pulse Rate of 50
beats per minute
62

RR-20 bpm
PR-42 cpm
T-38C
Hemoglobin
count 93 g/L
Hematocrit
0.29
palpebral
conjunctiva
and
paleness.
Then the
oxygen being
supplied in
the body is
not enough
due to
decrease
production of
RBC, which
are
responsible
for the
tolerated. To
enhance venous return
(nurseslabs.com. July
27, 2014).
6. Discouraged
sitting/standing for long
periods, wearing
constrictive clothing,
crossing legs. To
improve and facilitate
good circulation
(nurseslabs.com. July
27, 2014).
7. Checked for calf
tenderness. May
indicate thrombus
63

oxygenation
of tissues
thus leading
to ineffective
tissue
perfusion.
(Pathophysiol
ogy by
Bullock. Date
of retrieval:
July 27,
2014)
formation
(nurseslabs.com. July 27,
2014).
8. Instructed to avoid
strenuous activities. To
conserve energy
(nurseslabs.com. July 27,
2014).
9. Restricted sodium,
fluid and fat intake as
indicated. To decrease
excess fluid volume
(nurseslabs.com. July 27,
2014).
10. Regulated IVF as
ordered. To maintain
64

hydration
(nurseslabs.com. July 27,
2014).
11. Promoted adequate
bed rest. To provide
adequate wellness
(nurseslabs.com. July 27,
2014).
Dependent
8. Administered
medications as
prescribed. To help
relieve the signs and
symptoms experienced
by the patient
(nurseslabs.com. July
65

27, 2014)
Collaborative
11. Instructed the
watcher or any member
of the family to lessen
foods high in salt and
fat in his diet. To
prevent further
complications
(nurseslabs.com. July
27, 2014)
12. Instructed patients
watcher about food rich in
iron. To help increase
Hgb count
(nurseslabs.com. July 27,
66

2014)
13. Advised the watcher
to stay and talk with the
patient. To help lessen
the pain and anxiety that
the patient is currently
feeling. (nurseslabs.com.
July 27, 2014)








67

Date and
Time
Assessment Need Nursing
Diagnoses
Planning Nursing interventions Evaluation
July 23, 2014
7-3
S: Malipong
ko kung
mubangon,
as verbalized.
Luya kaayo
akong lawas.
Kapoy ilihok,
as verbalized.
O:
-pale
palpebral
conjunctva
-pale and dry
lips
-needs
P
H
Y
S
I
O
L
O
G
I
C

N
E
E
Risk for injury r/t
Dizziness

R: Dizziness
may be caused
by your fever
which could be
caused by some
sort of bacteria
or virus. Your
body raises its
own temperature
to try and kill off
the bacteria or
virus as by
After 8 hours of
nursing care,
dizziness will
not be felt as
evidenced by:
- (-) pale
palpebral
conjunctva
- (-) pale and
dry lips
-do not need
further
assistance in
ambulation
-wide range of
Independent:
1. VS monitored and
recorded. R: To have
baseline data.
2. Established rapport.
R: To gain trust and
cooperation.
3. Stayed with the client
and made arrangements
to have someone else to
be there. R: To have
someone who can assist/
help during ambulation.
4. Evaluated the place
with things that could
After 8
hours of
nursing
care, goal
partially
met, as
evidenced
by:
- Wala
naman ko
nalipong, di
parehas
ganina.
Luya ra jud
ilihok, as
68

assistance in
ambulation
-limited range
of motion
VS:
BP-120/90
mmHg
RR-20 bpm
PR-42 cpm
T-38C
Hemoglobin
count 93 g/L
Hematocrit
0.29
D


S
A
F
E
T
Y

A
N
D

S
E
C
raising the
temperature, the
cell of the
bacteria or the
receptors of the
virus can
become
denatured.
However due to
this rise in
temperature,
your body uses
up the fluid in
your system
quicker so that
you can become
dehydrated
motion noted
(Can sit up on
bed, turn to
sides, and
ambulate
without
assistance)

contribute to injury. R: To
modify the environment to
keep the safety.
5. Instructed the patient
to avoid sudden head
movements and any
strenuous activities. R:
This could aggravate the
dizziness felt by the
patient.
Dependent:
6. Administered
paracetamol as ordered.
R: Analgesics; for mild
pain and fever.
Collaborative:
7. Encouraged the
verbalized.
- (+) pale
palpebral
conjunctva
- (+) pale
and dry lips
-Needs
assistance
in
ambulation
-Can sit up
on bed
without
assistance


69

NANDA 2006
U
R
I
T
Y
which can lead
to the feelings of
dizziness and
light
headedness
(http://health.blur
tit.com/185895/
what-would-
cause-a-fever-
and-dizziness,
Date Retrieved:
July 27, 2014).
companions to assist
during ambulation. R: To
avoid any injuries that
could contribute to fear.
8. Instructed the watcher
not to leave the patient
alone. R: To avoid any
sudden injury.