West Visayas State University

COLLEGE OF NURSING
La Paz, Iloilo City

NURSING CARE PLAN

Name of Patient: R.V.G.
Age: 63 y/o

Clustered Cues
7/20/15
8:00 am

Weight loss of
20kg from
previous weight
of 63kg
Appears weak,
lethargic, and dry
oral mucosa
membrane noted

BMI: 16.8

Decreased serum
albumin:16.94
g/L

Able to consume
50% of meal

Decrease
appetite noted

Nursing
Diagnosis
Imbalance
Nutrition: Less
than body
requirements r/t
decrease in
appetite

Ward/Bed no.: MSSW-10

Rationale
Intake of nutrients
insufficient to meet
metabolic needs

Attending Physician: Dr. D

Impression/Diagnosis: Rectal adenocarcinoma well differentiated, 12cm from,
Anal verge stage III (T2N1M0) s/p Hartmanns procedure

Outcome Criteria

The patient will be

able to consume
100% of meal served
with good appetite
Among the many
by 8:00 am of July
causes of anorexia in 22, 2015.
the cancer patient
are alterations in
taste, manifested by
increased salty, sour,
and metallic
taste sensations, and
altered responses to
sweet and bitter
flavors, leading to
decreased appetite,
decreased nutritional
intake, and proteincalorie malnutrition.
This sense of
fullness occurs
secondary to a
decrease
in digestive
enzymes,

Nursing Interventions

Rationale

7/22/15
8:00 AM

Independent:
1. Measure height, weight, and 1. If these measurements fall
skinfold thickness, or other
below minimum standards,
anthropometric
clients chief source of
measurements, as appropriate.
stored energy, fat tissue, is
Ascertain amount of recent
depleted.
weight loss. Weigh daily or as
indicated.
2. Obtain nutritional history
and thorough nutritional
assessment; include SOs in
assessment.

Evaluation

2. Patients perception of
actual intake may differ.

3. Determine etiologic factors 3. Proper assessment guides

intervention.
for reduced nutritional intake.
4. Auscultate bowel sounds.

4. During aggressive
nutritional support, patient
may gain 0.5 lbs per day

5. Evaluate total daily food

intake

5. Reveals possible cause of

malnutrition changes that
could be made in clients
intake.

GOAL MET
The patient was able to
consume 100% of meal
served with good appetite
by July 21, 2015 at 8:00
am.

abnormalities in the
metabolism of
glucose and
triglycerides, and
prolonged
stimulation of
gastric volume
receptors, which
convey the feeling of
being full.

Source:
Doenges, M. E et al.;
Nurses Pocket Guide;
Diagnoses, Prioritized
Interventions and
Rationales, Edition 12th
Hinkle, J. L. & Cheever. K.
H; Brunner&Suddarths
Textbook of Medical
Surgical Nursing 12th
edition

6. Recommend small, frequent 6. May reduce fatigue and

meals and/ or between
thus enhance intake.
meal nourishment
7. Discourage beverages that
are caffeinated or
carbonated.

7. May decrease appetite and

may lead to earl satiety.

8. Assess for recent changes in

8. The consequences of
physiological status that
malnutrition can lead to a
may interfere with
further decline in the
nutrition.
patients condition that then
becomes self- perpetuating
if not recognized and
treated (Arrowsmith.1997).
9. Monitor state of oral cavity
9. Good state of oral cavity
and provide good oral
and good oral hygiene aids
hygiene before and after
in enhancing appetite; the
meals.
condition of the oral
mucosa is critical to the
ability to eat (Evans, 1992).
10. Offer small volumes of
10. Small volumes of liquids
light liquids as an
stimulate the
appetizer before meals.
gastrointestinal tract, which
enchances peristalsis and
motility (Roger-Seidel,
1991).
11. Prepare the client for
11. A pleasant environment
meals. Clear unsight
helps promote intake.
supplies and excretions.
Avoid invasive procedures
before meals.
12. Involve patient to
planning of food

12. To incorporate patients

preference on planning the
diet.

13. Weight at regular

intervals and document
results

13. Monitor effectiveness of

dietary plan.
14. Necessary to make an
accurate nutritional
assessment.

14. Keep strict monitoring

and documentation of
intake, output, and calorie
intake
15. Helps patient understand
on how nutrition can help
15. Discuss importance of
on their recovery.
adequate nutrition.
Collaborative:
1. Monitor laboratory values
that indicate nutritional
well-being/ deterioration:
Serum albumin
RBC and WBC counts
Serum electrolyte
values
2. Administer medications
and supplements as
indicated and ordered by
the physician.
3. In collaboration with the
dietician. Determine the
number of calories required
to provide adequate
nutrition and realistic
weight gain.
Students Name:________________________

1. Helps identify the degree of

biochemical imbalance or
malnutrition and influences
choice of dietary
interventions.

2. To increase nutritional
intake and helps in treating
the disease.
3. To provide adequate
nutrition and realistic
weight gain.

Clinical Instructor:_____________________
West Visayas State University
COLLEGE OF NURSING
La Paz, Iloilo City

NURSING CARE PLAN

Name of Patient: R.V.G.
Age: 63 y/o

Clustered Cues
7/20/2015
8:00 a.m.
Basta nagakabuhi
ka, may ikasarang ka
gid nga lampuwasan
ang problema
Gapanugid ako sa
akon asawa kag
ginaistoryahan
namon ato hasta nga
mahibalu-an namon
kung paano
masolbar
Seeks social support
Aware of possible
environmental
changes

Nursing
Diagnosis

Ward/Bed no.: MSSW-10

Attending Physician: Dr. D

Impression/Diagnosis: Well-differentiated Rectal adenocarcinoma, 12cm from,
Anal verge stage III (T2N1M0) s/p Hartmanns procedure

Rationale

Outcome Criteria

A pattern of
cognitive and
behavioral efforts to
manage demands
that is sufficient for
well-being and can
be strengthened.

The patient will be

able to identify
effective coping
patterns and meet
psychological needs
as evidenced by
verbalization of
identified options
and use of resources
by 12:00 nn of July
20, 2015.

Nursing Interventions

Rationale

Independent:
Readiness for
enhanced
coping

Source:
Doenges, M. E et al.;
Nurses Pocket Guide;
Diagnoses, Prioritized
Interventions and
Rationales, Edition 12th

1. Determine stressors that are

currently affecting client.

1. Accurate identification of
situation that client is
dealing with provides
information for planning
interventions to enhance
coping abilities.

2. Identify social supports

available to client.

2. Available support systems

can provide client with
ability to handle currents
stressful events and can
help client move forward
to enhance coping skills.

3. Review coping strategies

client is aware of and
currently using.

3. The desire to improve

ones coping ability is
based on an awareness of
the current status of the
stressful situation.

4. Determine alcohol intake,

other drug use, smoking
habits, and sleeping and

4. Use of these substances

impairs ability to deal with
anxiety and affects ability

Evaluation
7/20/2015
12:00nn
GOAL MET
The patient was able to
identify effective coping
patterns such as talking
and sharing to his children
and other family members
about his concerns, spend
some time with his
grandchildren and with his
friends. Able to verbalize,
kay na agyan ko na ni
nga sakit, amat-amaton ko
na ni dula ang akon paginom kag pag
panigarilyo.

eating patterns.

to cope with life stressors.

Identification of impaired
sleeping and eating
patterns provides clues to
need for change.

5. Assess level of anxiety and

coping on an ongoing
basis.

5. Provides information for

baseline to develop plan of
care to improve coping
abilities.

6. Note speech and

communication patters.

6. Assess ability to
understand and provide
information necessary to
help client make progress
in desire to enhance
coping abilities.

7. Active listen and clarify

clients perceptions of
current status.

7. Reflecting clients
statement and thoughts
can provide a forum for
understanding perceptions
in relation to reality for
planning care and
determining accuracy of
interventions needed.

8. Review previous methods

of dealing life problems.

8. Enables client to identify

successful techniques used
in the past, promoting
feelings of confidence in
own ability.

9. Discuss desire to improve

ability to manage stressors
of life.

9. Understanding clients
desire to seek new
information to enhance
life will help client
determine what is needed
to learn new skills of

coping.
10. Recommend involvement
in activities of interest.

Students Name:________________________
Clinical Instructor:_____________________

West Visayas State University

10. For client to decide for

themselves on what
coping strategies are
adaptive for them. Most
people find enjoyment and
relaxation in different
activities.

COLLEGE OF NURSING
La Paz, Iloilo City

NURSING CARE PLAN

Name of Patient: R.V.G.
Age: 63 y/o

Clustered Cues
7/20/15
8:00 am
Maghulag ga ngutngut pilas ko
As verbalized;
Pain rate of 5/10;
Facial grimace and
guarding noted;
Limited range of
motion; muscle
strength of 3/5;

Nursing
Diagnosis
Acute pain r/t
incision site

Ward/Bed no.: MSSW-10

Rationale
Unpleasant sensory
and emotional
experience arising
from actual or
potential tissue
damage or describe
in terms of such
damage; sudden or
slow onset of any
intensity from mild
to severe with an
anticipated or
predictable end and
a duration of less
than six months.
Pain is usually
viewed in the
context of tissue
injury. Nociceptive
stimuli are
objectively defined
as stimuli of such
intensity that they
cause or are close to
causing tissue

Attending Physician: Dr. D

Impression/Diagnosis: Well-differentiated Rectal adenocarcinoma, 12cm from,
Anal verge stage III (T2N1M0) s/p Hartmanns procedure

Outcome Criteria
The patient will be
able to verbalize
pain relief with a
pain rating scale of
2/10 by 2:00 pm of
July 20, 2015.

Nursing Interventions

Rationale

Evaluation
7/20/15
2:00 pm

Independent:
1. Monitor vital signs

1. To obtain baseline data.

GOAL MET

2. Assess pain
characteristics: quality
(sharp, burning); severity
(0 -10 scale); location;
onset (gradual, sudden);
duration (how long);
precipitating or relieving
factors.

2. A good assessment of pain

will help in the treatment
and ongoing management
of pain.

The patient was able to

verbalized wala naman
ga sakit with a pain
rating scale of 2/10 by
July 20, 2015 at 2:00 pm.

3. Assess for non-verbal

signs of pain.

3. Some patients may

verbally deny pain when it
is still present.
Restlessness, inability to
focus, frowning,
grimacing and guarding of
the area may be nonverbal signs of acute pain.

4. Anticipate the need for

pain relief and respond
immediately to complaints

4. The most effective way to

deal with pain is to
prevent it. Early
intervention can decrease

damage. Stimuli
used include
pressure from a
sharp object or such
as from a surgery. At
low levels of
intensity these
stimuli activate
nociceptors (pain
receptors), but
typically are
perceived only when
the intensity reaches
a level where tissue
damage occurs or is
imminent.

Source:
Doenges, M. E et al.;
Nurses Pocket Guide;
Diagnoses, Prioritized
Interventions and
Rationales, Edition 12th ed.
Porth, C.M.,
Pathophysiology:Concepts
of Altered Health States, 6th
edition.

Students Name:________________________
Clinical Instructor:_____________________

of pain.

the total amount of

analgesic required.Quick
response decreases the
patients anxiety regarding
having their needs met
and demonstrates caring.

5. Eliminate additional
stressors when possible.
Provide rest periods, sleep
and relaxation.

5. Outside sources of stress,

anxiety and lack of sleep
all may exaggerate the
patients perception of
pain.

6. Institute nonpharmacological
approached to pain
(detraction, relaxation
exercises, music therapy,
etc.).

6. Non-pharmacological
approaches help distract
the patient from the pain.
The goal is to reduce
tension and thereby
reduce pain.

Collaborative:
1. Give analgesics as
ordered and evaluate
the effectiveness.

1. Narcotics are indicated

for severe pain. Pain
medications are
absorbed and
metabolized
differently in each
patient, so their
effectiveness must be
assessed after
administration.