Manila Doctors College

Pres. Diosdado Macapagal Blvd. Metropolitan Park, Pasay City.

 CUES/Data Nursing Goals and Intervention Rationale Evaluation
Diagnosis Objectives
Subjective: Acute pain After 8housr of nursing Independent
related to intervention the clientManila Doctors College
inflammation of will beDiosdado
Pres. able to: Macapagal Blvd. Metropolitan Park, Pasay City.
gastric mucosa
1)report pain is
relieved or controlled • Maintain accurate record • Provides information
of I&O. Assess skin/ about fluid status/
2) follow prescribed mucous membranes, circulating volume and
pharmacological peripheral pulses and replacement needs.
regimen capillary refill.

3)verbalize • Assess for unusual • Prothrombin is reduced

nonpharmacologic bleeding, petechiae, and coagulation time
methods that provide epistaxis. prolonged when bile
relief flow is obstructed,
increasing risk for
4) bleeding/ hemorrhage.

 Perform frequent oral • Decreases dryness of

hygiene with alcohol-free oral mucous
mouth wash; apply membranes; reduces
lubricants risk of oral bleeding.]

• Vital signs changes

• Monitor vital signs as such as increased heart
appropriate. rate, decreased blood
pressure, and
increased temperature
indicate hypovolemia

• Prolonged vomiting,
• Describe and Monitor for gastric aspiration, and
signs and symptoms of restricted oral intake
increased and continued can lead to deficits in
nausea and vomiting, sodium, potassium, and
abdominal cramps, chloride.
hypoactive or absent of
bowels sounds, depressed
respirations.

• Decreases GI
Collaborative secretions and motility.
• Keep patient NPO as • Reduces Nausea and
necessary. prevents vomiting.
• Administer antiemetics. • Maintains circulating
• Administer IV fluids, volume and corrects
electrolytes and Vitamin K. imbalances.
(Source: Nursing Care Plans
 Manila Doctors College
Pres. Diosdado Macapagal Blvd. Metropolitan Park, Pasay City.

Patient: Justino Sadio Fegio Room: 337#4 Age:39 Chief complaint: Vomiting September 19, 2008

Cues/Data Nursing Diagnosis Rationale Goals and Objectives Interventions Rationale Evaluation
 Manila Doctors College
Pres. Diosdado Macapagal Blvd. Metropolitan Park, Pasay City.

Subjective: Constipation related to Decrease in normal After 1 hour of nursing After 1 hour of nursing
• According to the insufficient physical frequency of defecation intervention the client Independent: intervention the client
client’s wife, “Hindi activity, and insufficient accompanied by difficult will be able to establish was able to establish
pa siya nakakadumi, fluid intake. or incomplete passage of normal pattern of bowel normal pattern of bowel
mga tatlong araw stool and/or passage of functioning as evidenced functioning as evidenced
na..Pero bago pa excessively hard, dry by: • Encourage adequate • May reduce potential by:
siya maconfine dito stool. • Patient will fluid intake. for constipation by
ndi siya regularly increased fluid improving stool
nakakadumi every (Nurse’s Pocket Guide intake consistency and • Patient was able
other 3days tapos p.162) (2000ml/hr) stimulating to increase fluid
nahihirapan siya sa peristalsis; can intake(2000ml/hr)
pagdumi. ” prevent dehydration
• Vomiting • Inform the client the associated with
• As verbalized by the health benefits and diarrhea. • Patient was able
wife his husband • Patient will physiologic effects of to exercise
doesn’t exercise, “ exercise exercise. • Activity influences adequate amount.
hindi na adequate • Instruct her about bowel elimination by
nakakapagexercise amount. appropriate types of improving muscle
asawa ko pahinga exercise of his level tone and stimulating
lang talaga siya sa of health, in peristalsis.
bahay lagi lang siya collaboration with • Any individual
nakahiga.”. physician. beginning an
• Age:39 (collaborative) exercise program
should consult a
Objective: physician primarily
• Anorexia for cardiac
evaluation. The
• On clear liquids diet • Explain to patient the client’s age and lack • Patient was able
• With NGT connected factors that of activity should be to verbalize
to bed side bottle. contribute to considered in understanding of
• With total of 550 cc • Patient will constipation. Like planning the level of factors and
of drainage and verbalize insufficient fluid activity. appropriate
500ml of urine understanding of intake, insufficient interventions
output from 1400H- factors and fiber intake, • To increase related to
2200H. appropriate insufficient activity individual
understanding of
• With 330cc intake of interventions and medications patient, and family situation.
 Manila Doctors College
Pres. Diosdado Macapagal Blvd. Metropolitan Park, Pasay City.

water and 550cc of related to such as opiates or members about the

Lactated Ringer’s individual iron salts. factors that
parenterally from situation. • Provide information contribute
1400H-2200H. that increase in fiber constipation.
intake, fluid intake,
and exercise are
interventions for • Patient was able
constipation. • To increase to verbalize
• Discuss use of stool understanding of comfort of stool
softeners, mild patient and family passage
• Patient will stimulants, bulk regarding measures
verbalize comfort forming laxatives. to be taken to
of stool passage Collaborative: establish normal
• Give Laxatives, pattern of bowel.
enemas, as • Facilitates defecation
indicated. when constipation is
present.

• Prophylactic use
may prevent
further
complications in
some patients.
Source( Nursing Care
plans)
 Manila Doctors College
Pres. Diosdado Macapagal Blvd. Metropolitan Park, Pasay City.

Patient: Justino Sadio Fegio Room: 337#4 Age:39 Chief complaint: Vomiting September 20, 2008

Cues/Data Nursing Diagnosis Rationale Goals and Objectives: Interventions: Rationale: Evaluation:

Hyperthermia related to Body temperature After 1 hour of Nursing After 1 hour of Nursing
Objective: dehydration elevated above normal Intervention the client Intervention the client
Temp: 38.3 range. temperature will Independent temperature decreased
PR: 108 decrease from 38.3 to from 38.3 to 37.4 as
RR:21 37.4 as evidenced by: evidenced by:
• Increased pulse and • The patient will • Monitor heart • Dysrhythmias • The patient was
respiratory rate maintain normal rate and rhythm and ECG are able to maintain
• The skin is warm to range of vital changes are normal range of
touch signs common due to vital signs
• Flushed skin electrolyte
• With NGT connected imbalance,
to bed side bottle dehydration and
• With total of 550 cc specific action of
of drainage and catecholamines,
500ml of urine and direct effects
output from 1400H- of hyperthermia
2200H. on blood.
• On clear liquids diet  Monitor
respirations • Hyperventilation
• With 330cc intake
may initially be
of water and 550cc
present, but
of Lactated Ringer’s
ventilator effort
parenterally from
may eventually
1400H-2200H.
be impaired by
seizures,
 Monitor and hypermetabolic
record all sources state.
of fluid loss such
as urine, and • To assess fluid
and electrolyte
 Manila Doctors College
Pres. Diosdado Macapagal Blvd. Metropolitan Park, Pasay City.

• The patient will vomiting. losses; oliguria/ • The patient was

response to renal failure may able to response
interventions/ occur due to to interventions/
teaching actions • Discuss the dehydration . teaching actions
performed. importance of performed.
adequate fluid • To prevent
intake. dehydration
 Maintain bed rest
• To reduce
metabolic
 Administer demands/oxygen
antipyretic consumption.
orally/rectally as • To decrease the
ordered. temperature.
(collaborative)

 Administer
replacement
fluids ad • To support
electrolytes circulating
volume and
tissue perfusion.
• Patient will  Lavage body • Patient was able
increase fluid cavities with cold to increase fluid
intake. water; apply • To promote heat intake.
tepid sponge loss by
bath. evaporation and
conduction
 Promote surface
cooling by means
of undressing. • To promote heat
loss by radiation
and conduction.
• Instruct the
patient to
increase fluid • To replace fluid
 Manila Doctors College
Pres. Diosdado Macapagal Blvd. Metropolitan Park, Pasay City.

intake. and electrolyte

loss.
 Manila Doctors College
Pres. Diosdado Macapagal Blvd. Metropolitan Park, Pasay City.

NURSING CARE PLANS

Jean katrine t. panganiban
Group 3

Mr. ronaldo tan