IX.

NURSING CARE PLANS

NURSING CARE PLAN #1

ASSESSMENT
Subjective cues:

DIAGNOSIS

Dali ra ko
Decreased cardiac

ug cge pod ko ga

output related to

nursing

EVALUATION
Short term:
After 3 hours of

1 Encouraged

1 Volume

nursing intervention,

increase oral

therapy may

patient will be able

fluid intake 1-

be required to

to:

2L/day as

maintain

adequate

tolerated.

adequate filling

cardiac

adequate

pressures and

output as

conduction, and

cardiac output

optimize

evidenced by

cardiac muscle

as evidenced by

cardiac output.

BP of 120/90

impaired

verbalized by

contractility,
alteration in heart

rhythm and

disease

RATIONALE

intervention,

palpitate. As

Objective cues:

IMPLEMENTATION
Independent:

After 3 hours of

gakapoyon tungod

patient

PLANNING
Short term:

Maintain an

systolic BP

2 Administered

patient was able to:

2 Serious side

Maintain an

mmHg

Patient is

within 20

medications as

effects may

diagnosed with

mmHg of

prescribed,

occur if vital

regular heart

cardiomegaly

baseline

noting

parameters are

rate of 79

Maintain a heart

response and

not checked

BPM with

on September

Maintained a

2013.

rate of 60-100

watching for

prior to

regular

(+) Atrial

BPM with

side effects

admission.

rhythm

fibrillation on

regular rhythm

and toxicity.

ECG

Maintain a urine

3 Monitored BP

3 General or

Maintained a
urine output

(+) Tachypnea

output of 30ml

lying, sitting,

orthostatic

of more than

(+) Pallor

or greater

and standing, if

hypotension

30 ml

(+) Bipedal
edema grade 1

Maintain strong

able. Note

may occur as a

peripheral

widened pulse

result of

strong

pulses, and a

pressure.

excessive

peripheral

peripheral

pulses and a

vasodilation

warm skin

and decreased

with a

circulating

temperature

volume.

of 36.3

Widened pulse

degrees

pressure

Celsius.

warm skin

Maintained

reflects
compensatory
increase in
stroke volume

Long term:

Long term:

and decreased
systemic

After 8 hours of

vascular

nursing intervention,

nursing

resistance

patient was able to:

intervention, patient

(SVR).

After 8 hours of

will be able to:

4 Placed the

4 When fluid

Maintain
eupnea

Maintain

patient in a

overload is the

eupneic

semi-fowlers

cause, upright

from

respirations

to high-fowlers

positioning

pulmonary

Absent from

position.

reduces

crackles

Be absent

pulmonary

preload and

crackles

ventricular

person,

Maintain

filling/for

place, and

orientation to

hypovolemia,

time.

person, place,

supine

and time

positioning
increases
venous return
and promotes
diuresis.

Be oriented to

5 Maintained

5 Activity

physical and

restriction and

emotional rest

a quiet

by restricting

environment

activity, provide

reduces

a quiet and

oxygen

relaxed

demands.

environment,

Attention to

organized

priority care

nursing and

delivery

medical care,

optimizes use

monitor

of patients

progressive

limited energy

activity within

resources.

limits of

Careful activity

cardiac

progression

function.

prevents
overexertion
and stress on

the
cardiopulmona
ry system.
6 Monitored

6 Rest is

sleep patterns;

important for

administer a

conserving

sedative as

energy.

needed.
7 If dysrhythmias

7 Both

occur,

tachydysrhyth

determine the

mias and

patients

bradydysrhyth

response,

mias can

document and

reduce cardiac

report if

output and

significant or

myocardial

symptomatic.

tissue
perfusion.

Collaborative:

8 Furosemide is
for treatment of

8 Administered
furosemide
40mg tab
OD PO as

edema, thus
relieving
cardiac
workload.

ordered by
physician.

9 Failing heart
may not be
able to
9 Administered
oxygen therapy
as prescribed
(d/c February
14, 2015)

respond to
increased
oxygen
demands.

NURSING CARE PLAN #2

ASSESSMENT
Subjective cues:

DIAGNOSIS

Dili kay ko
ganahan mukaon
wala koy gana.
Patient verbalized
loss of appetite.

Imbalanced
Nutrition: less than
body requirements
related to
hypermetabolism
and loss of appetite

PLANNING
Short term:

IMPLEMENTATION
Independent:

After 2 hours of

1.) Encouraged

nursing

client to choose

interventions, the

foods that are

patient will be able

to:

appealing.
2.) Promoted
pleasant,

Objective cues:

Verbalize
understanding of
causative factors

Hyperactive

when known and

necessary

bowel sounds
Diarrhea upon

admission (8x)
Wt 38 kg
BMI 18.1;
underweight

interventions;
Demonstrate
behaviors, life
style changes to
regain and/or

RATIONALE

1.) To stimulate
appetite.

EVALUATION
Short term:
After 2 hours of
nursing
interventions, the
patient was able to:

2.) To enhance
intake.

relaxing

understanding of

environment,

causative factors

including

when known and

socialization
when possible.
3.) Minimized
unpleasant
odors/sight.
4.) Promoted

Verbalized

necessary
3.) This may have a

interventions.
Failed to

negative effect

demonstrate

on

behaviors, life

appetite/eating.
4.) Limiting fluids 1

style changes to
regain and/or

maintain proper

adequate/timely

hour prior to

maintain proper

weight

fluid intake.

meal decreases

weight.

possibility of
5.) Provided diet
Long term:

modifications as
indicated, for

At the end of 3 days

of nursing

example:
increase in

interventions, the

protein,

patient will be able

carbohydrates,

to:

calories, and

Demonstrate

early satiety.
5.) These
modifications
may enhance
intake with
adequate
nutrients.

Long term:
At the end of 3 days
of nursing
interventions, the
patient will be able
to:

small feedings

underweight with

with snacks.

maintained BMI

progressive
weight gain

Client still

Collaborative:

toward goal;
Maintain a well- 6.) Consult
balanced diet
dietitian/nutrition
with adequate
al team at

of 18.1.
Failed to
demonstrate

6.) To implement

progressive

interdisciplinary

weight gain

team

toward goal.

vitamins and

MRXUHI as

minerals.

necessary.

management.

Failed to
maintain a wellbalanced diet
with adequate
vitamins and
minerals.

NURSING CARE PLAN #3

ASSESSMENT
Subjective cues:

DIAGNOSIS

PLANNING
Short term:

IMPLEMENTATION
Independent:

Dili kai ko maka

Activity Intolerance

At the end of 2

1.) Adjusted daily

lihok-lihok ug

Related to:

maka limpyo-

Imbalance between

lipmyo sa balay

oxygen supply and

karun kai basin mu

demand

hours, the patient

activities of

will be able to:

patient

RATIONALE

1.) To prevent
overexertion

EVALUATION
Short term:
At the end of 2
hours, the patient
was be able to
Identify negative

Identify negative 2.) Maintained

2.) Promotes

factors affecting

kalit ug palpitate

factors affecting

position of

maximal

activity tolerance

ug kusog ako

activity tolerance

comfort, with

inspiration;

and eliminates or

dughan ug basin

and reduce their

head of bed

enhances lung

reduces their effects

mag lisod kog

effects when

elevated (semi-

expansion and

when possible and

ginhawa. Maka

possible.
Use identified

fowlers to

ventilation

be able to use

lihok man ko pero

ginagmay lang

techniques to

kanang di ra kai ko

enhance activity

mahago. as

tolerance.

3.) Planned care to

carefully balance
rest periods with

verbalized by the

activities

patient.
Long term:

identified techniques

fowlers position)

to enhance activity
3.) To reduce

tolerance.

fatigue
Long term:

4.) Provided positive

Objective cues:

4.) Helps to

After 24- 72 hours of

After 24- 72 hours

atmosphere

minimize

nursing intervention,

of nursing

while

frustration.

the patient will be

Exertional

intervention, the

acknowledging

able to exhibit being

chest pain

patient will be able

difficulty of the

free of exertional

to:

situation for the

chest pain and

noted
slightly

slouching
Occasional

Tremors noted
Increased

Exhibit being
free of exertional
chest pain and

respiratory

occasional

rate: 36 cpm
Heart rate:

tremors.
Report

96bpm

measurable
increase in
activity tolerance

client.
5.) Assisted with
activities and

occasional tremors
5.) To protect client
from injury.

provide clients

tolerance.

devices
6.) Planned with the
SO maximal
activity within
clients ability.

Collaborative:

measurable
increase in activity

use of assistive

client and her

and report

6.) Promotes the

idea of normalcy
of progressive
abilities.

7.) Administer
propanolol 40
mg 1 tab TID

7.) To reduce

after meals, as

contractility of

indicated by

the heart and to

physician

improve
tolerance to
activities

NURSING CARE PLAN #4

ASSESSMENT
Subjective cues:

DIAGNOSIS

PLANNING
Short term:

IMPLEMENTATION
Independent:

RATIONALE

EVALUATION
Short term:

 Ga laslas na siya
sauna tungod sa
iyang mga
problema labun na
tungod sa iyang

After 2 hours of
Risk for suicide
related to history of
previous suicide
attempt

observation is

nursing intervention,

intervention,

frequently. Do

required so that

patient was able to:

patient will be able

this through

intervention can

to:

routine activities

occur if required

and interactions;

to ensure client's

understandin

Express

avoid appearing

(and others')

g on

decreased

watchful and

safety.

teachings,

Objective cues:

about feelings
appropriately

Suicidal history
as noted in

Decrease onset
of agitations

chart

Agitation noted

Occasionally
spurs

suspicious.
2.) Observed for
suicidal
behaviors: verbal
statements, such
as "Im going to
kill myself." and
nonverbal

Long term:

inappropriate
response

After 2 hours of

clients behavior

anxiety, talk

1.) Close

nursing

sakit karun as
verbalized by SO

1.) Observed

After 2 days of

behaviors, such
as giving away
cherished items

Verbalize

and actions
2.) Clients who are
contemplating

performed

Have lesser

suicide often

onsets of

give clues

agitation

regarding their
potential
behavior. The

Long term:

clues may be
very subtle and

After 2 days of

require keen

nursing intervention,

Financial

nursing

concerns are

intervention, patient

present

will be able to:

Free from self

harm

Left wrist (+)

slash marks

swings.
3.) Identified stimuli
that may trigger

Diagnosed
Thyroid storm

and mood

Living alone

current mood
4.) Removed all

patient was able to:

skills by the
nurse.
3.) To intervene with

ideation of

the stimuli to
prevent agitation
to the patient.
4.) Client safety is a

Verbalized no
harm

Free from

Free from

dangerous

ideation of self

objects from

harm

clients

Obtains no

environment

improvement

levels.
5.) Be with the client

in mood and

access to
harmful objects

a change in

assessment

Show an
improvement in
mood

during feelings of
uneasiness and
agitation.

harm

nursing priority

Show

is able to
5.) Presence of a
trusted individual
provides a
feeling of
security and may
help to prevent
rapid escalation

6.) Discussed

self-afflicted

of anxiety.

communicate
well.

information

6.) It is believed that

about the role of

problems in the

neurotransmitter

serotonin system

s in predisposing

may cause an

and individual to

individual to be

beginning this

more aggressive

behavior

and impulsive
especially
combined with

7.) Assisted client to

identify feelings
of and behaviors
that that precede
desire for self
harm

an environment.
7.) Early recognition
of recurrent
feelings provides
client opportunity
to seek other
way of coping

NURSING CARE PLAN #5

ASSESSMENT
Subjective cues:

DIAGNOSIS

PLANNING
Short term:

IMPLEMENTATION
Independent:

RATIONALE

EVALUATION
Short term:

wala ko kasabot
sa pag explain sa
nurse sa ako
tambal na imnon.
Wala pud ko

After 2 hours of
Knowledge Deficit
regarding treatment
regimen and selfcare

important

nursing intervention

interventions the

misconceptions

starting point in

the patient was able

patient will be able

regarding her

education.

to verbalize her

to:

present condition
2.) Determined

Verbalize
understanding to

tambal nga

her treatment

antibiotic, para

regimen
Identify lifestyle

patients learning
style
3.) Provided an
atmosphere of

changes suitable

respect,

verbalized by the

for her condition.

openness, trust
and collaboration

patient.
Long term:

Agitated
Confused

4.) Gave clear,

thorough

Objective cues:
After 8-48 hours of

explanations and

nursing

demonstrations.

intervention, the

understanding on
2.) Facilitates
success in
mastery of

heart. As

After 2 hours of

existing

kaunon. Naa koi

man to sa ako

1.) Provides an

Nursing

kabalo unsay
bawal ug dili bawal

1.) Identified any

knowledge.
3.) Important in

her treatment
regimen and her
lifestyle changes
specifically on her
diet.

providing
education to
patients values
and beliefs.
4.) For easy

Long term:

understanding
After 8-48 hours of
nursing intervention,
the patient showed

Inaccurate

patient will be able

follow through

to follow therapeutic

teaching

concentrate

therapeutic regimen

of instruction

regimen and

sessions on a

more completely

and started first

on treatment

demonstrate

single concept or

on the concept

steps to lifestyle

regimen.

lifestyle changes if
necessary

5.) Focused

idea.
6.) Encouraged
questions
7.) Provided Patient
with Health
Teachings with
emphasis on:
8.) Adequate

5.) Allows learner to

being discussed.
6.) Learners often
feel shy or
embarrassed.
7.) To promote wellbeing of the
patient.
8.) To encourage

Nutrition; eating

ongoing support

a well-balanced

for patient.

diet with
increase intake
in green leafy
vegetables,
vitamin-rich
fruits, and fruit

9.) Prevents fatigue

compliance to

modification.

drinks
9.) Enough Sleep
and rest

and decreases
cardiac
workload.
10.) Promotes
circulation.

10.) Daily, proper

exercise; e.g.
brisk walking for
30 minutes,
deep breathing.
11.) Included

11.) Involvement
with SOs
promote

significant others

compliance of

whenever

treatment.

possible in giving
information.