X.

Nursing Care Plan

Cues/ Needs Nursing Rationale Goal and Interventions Rationale Evaluati

diagnosis Objectives
Subjective Data: Ineffective Immuno- After 4 hours INDEPENDENT: INDEPENDENT: After 4 hour
Makikita naming minsan kapag effective suppressed host of nursing 1. Assess the patients 1. It will help the patient nursing interve
from having
uubo cya parang maraming airway fever for days intervention, the knowledge of contributing comply towards his client and the c
plema tapos minsan tuloy tuloy clearance client and the causes, treatment plan enhancement. family member
yung pagdhak nya ng plema na related to Entry of clients family and therapeutic 2. To ascertain status and partially met th
kpag hindi rin naming ipinilit na sticky microorganism members will: procedures. note the progress. manifested by:
to nasal
sabihin sa kanya na ilabas nya secretions passages
2. Auscultate breath sounds 3. Improvement can help the a. The patient n
lulunukin nya lang as seen after a. Expectorate his and assess air movement patient to comply for total help of his relati
verbalized by the client coughing and Invasion of the secretions every 3. Observe for improvement wellness. expelling his se
sometimes respiratory time he coughs. in symptoms. 4. To open or maintain open b. The patient d
system
Objective Data: swallowing b. Demonstrate 4. Position the client in semi airway and decrease swallow his sec
Dyspnea if coughing the Activation of reduction of fowlers position. difficulty in breathing. after coughing.
Use of accessory muscles secretions Immune congestion of 5. Keep the environment 5. To not aggravate the c. The patient v
when inhalation & response secretions allergen free situation of the patient. that he underst
exhalation if coughing c. Verbalize 6. Increase fluid intake of 5-8 6. To help liquefy secretions. he just nods bu
mucus
Whitish & sticky secretions production
understanding of glasses of water a day 7. It helps in expelling the attentive to the
seen on the tissue paper the cause of the within level of tolerance. secretions instructions. Bu
after coughing increase interventions and 7. Assist client for postural 8. Expectorating secretions family understa
Swallows the secretions if secretions therapeutic drainage and percussion. help in clearing the airway they verbalize t
not insisted to spit by the management. 8. Provide information about for proper exchange of would do it.
blocks the
family memebers. passageways d. Demonstrate the necessity of gasses and to decrease d. The patient v
water intake: 1 glass a day at behaviors to expectorating secretions difficulty in breathing. that he would i
210 cc Cough, not improve or versus swallowing them. 9. So they can help also to water intake fro
prominent maintain clear 9. Instruct the family motivate the patient in but again not a
Milk intake: 660cc a day
Source:
wheezes could be heard Contemporary
airway. members on how to easily expelling the secretions. but the family m
during exhalation Medical-Surgical expel the secretion of the (Nurses Pocket Guide, understands it a
Diagnose of having acute Nursing by Rick patient. MarilynnE.Doenges, pp.69-72) would instruct h
Daniels page (Nurses Pocket Guide, drink water mo
bronchitis
1057-1058
MarilynnE.Doenges, pp.69-72) from before.
Cues/ Needs Nursing diagnosis Rationale Goal and Objectives Interventions Rationale Evaluati
Subjective Data: Hyperthermia Weak immune After 1 hour of INDEPENDENT: INDEPENDENT: After 1 hour
Nilalagnat cya mya related to weak system nursing interventions 1. Identify the 1. Identifying the cause can interventions th
mya pero parang condition from having fever, the patient will be able underlying cause. help solve the condition and the patient
okay naman cya as secondary to diarrhea and to: 2. Note the easily. members had m
verbalized by the diarrhea cough for days Chronological and 2. Extreme ages are more goals as manife
patients relative. 1. Lower body developmental age. susceptible to have 1. Lower temp
temperature 3. Monitor and record infection due to weak 37.40C
Objective Data: Infection can between 36.50C the fluid loss. immune system. 2. The family
Temperature of easily manifest -37.50C 4. Perform Tepid Sponge 3. Dehydration can result monitor his
37.80C inside the body 2. Demonstrate Bath and electrolyte loss. temperatur
Warm body behaviors to 5. Promote surface 4. It can help lower the hour and th
Doesnt like to Increase Body monitor and cooling. temperature easily increase th
drink much Temperature promote 6. Provide a 5. Heat can be loss through water of th
water only a sip normothermia. comfortable radiation and conduction at least a
to a glass of Source: 3. Be free from environment for the 6. It help make the 125cc per h
water at least Contemporary complications client. environment to have less 3. The client is
50cc -210cc a Medical-Surgical 7. Increase fluid intake stress and promotes good any complic
day Nursing by Rick condition.
Diagnosed of Daniels page DEPENDENT: 7. To prevent dehydation
having AGE 1057-1058 1. Administer
antipyretics, DEPENDENT:
paracetamol 5ml, as 1. It can help lower the
ordered by the temperature easily.
physician.
(Nurses Pocket Guide,
(Nurses Pocket Guide, MarilynnE.Doenges, pp.288-
MarilynnE.Doenges, 289)
pp.288-289)

Cues/ Needs Nursing Rationale Goal and Interventions Rationale Evaluation

 diagnosis Objectives
Subjective Data: Drinks mostly After 2-3 INDEPENDENT: INDEPENDENT: After 2-3 hours of nursing
Medyo pumayat cya mula Imbalanced his milk and hours of 1. Ascertain 1. Knowing the intervention, the goal was
noong naadmit cya siguro mga Nutrition, drinks les water, nursing understanding of information about partially met. The client will
2 kg mga ginaan nya, Medyo less than doesnt want to intervention, individual nutritional the patients diet be able to improve his
wla rin kasi cyang ganang body eat foods he the client needs regimen helps the nutritional status as
kumain ditto sa hospital puro requiremen doesnt like and the 2. Assess weight, age, patient and the manifested by:
gatas at yung mga gusto ts related clients family body built, strength, patients family a. The patient nods when the
niyang pagkain yung kaakinin to members and activity. members to comply nurse is explaining but not
niya kundi isusuka niya lang decreased Decreased will: 3. Note daily intake with it. attentively listening. The
yun as verbalized by the appetite appetite a. Increase 4. Use flavoring agents 2. Provides comparative patient family members
patients relatives knowled like lemons and baseline from before understand the
Decreased ge about herbs as alternatives and after, so to see if instructions of the nurse
Objective Data: intake of the for salt there is and the interventions
Weight before:22kg nutritious food patients 5. Promote pleasant improvement. needed.
Weight now: 20kg daily relaxing environment 3. To know if the b. The patient eats
Mostly drinks milk at least Weight loss nutrition including patient is complying everything he wants but
a 660cc a day from 22 kg to al diet. socialization with the diet given to sometimes his family
Doesnt like to drink much 20kg during his b. Demon- 6. Discuss eating habits him. members insist him to eat
water only a sip to a glass hospital stay strate to the family 4. To enhance food healthy foods but
of water at least 50cc behavior members including satisfaction and sometimes he just spit it
-210cc a day Imbalance s to food preferences. stimulate appetite. out if he doesnt like the
If he doesnt like the taste nutrition less maintain 7. Encourage the client 5. To enhance intake of taste and not feels to eat
of the food he wouldnt than body his body and the clients food. it.
eat it like the spaghetti. requirement. weight family members to 6. To appeal likes and c. The patients develops a
Doesnt like foods with c. Increased feed him in small, desires that is good appetite; he starts to
vegetables. Source: appetite frequent meals. enclosed in his diet. drink fluids more but later
Poor appetite to eat. Nutrition and d. (Nurses Pocket Guide, 7. To stimulate appetite on while drinking water he
Want to just play around diet therapy by Increased Marilynn E. Doenges, pp. (Nurses Pocket Guide, would like to drink milk.
when it is eating time Ruth A. Roth pp food 347-351) Marilynn E. Doenges, pp. d. The patient bit by bit taste
loosing liquid stool at least 261- 262) intake 347-351) the spaghetti brought to
3x a day for 3 days already him but after a while he
vomits it.
Cues/ Needs Nursing Rationale Goal and Interventions Rationale Evaluation
 diagnosis Objectives
Subjective Data: Risk Fluid volume deficient After 2 hours Independent: Independent: After 2 hours of nursi
Medyo konti for fluid is a state in which an of nursing 1. Assess etiologic 1. These factors may be the interventions the patient
lang siyang volume individual is interventions the factors present. reason for having a decrease had partially met her goa
uminom ng deficient experiencing patient and the 2. Assess skin turgor/ fluid intake within the day. as manifested by:
tubig kasi mas related to decreased patients family oral mucous 2. Assessing skin turgor and oral 1. The patient nods tow
gusto niya gatas decrease intravascular, members will: membranes. mucus can help manifest if the instructions of th
mga isang baso intake of interstitial and 1. Identify 3. Note changes in there is already fluid volume nurse but the patient
lang naiinom oral fluids intracellular fluid on individual risk vital signs. deficient. family members
niya kada araw and the body. factors and 4. Establish individual 3. An alteration in vital signs understands that he h
as verbalized by loosing appropriate fluid needs shows signs of dehydration. to take and increase h
the clients liquid Decrease fluid intake interventions. 5. Encourage oral 4. Fluids must be replaced once fluid intake so that
family members stool at with 1 glass of water 2. Demonstrate intake. loosed to prevent dehydration. dehydration could be
least 3x a in a day and loosing behaviors of 6. Monitor I/O 5. Oral intake of fluids can help prevented and so tha
Objective Data: day. liquid stool at least 3x changes to balance being replace the fluids loss from the the fluid losses would
Dry lips a day. prevent aware of insensible urine and from loosing liquid replaced.
Less saliva development losses. stools. 2. The patient increases
decrease of fluid 7. Discuss individual 6. Monitoring the I/O can help tell fluid intake of half a
fluid intake Decrease fluid in the volume risk factors and if the fluid intake is equal or glass an hour through
The patient Body deficit. potential problems almost equal to the fluid loss the help of the family
only drinks 1 and specific and helps ensure accurate fluid members. The patien
glass of Shows possible signs interventions status and so that dehydration parents instructed th
water with of fluid volume toward the family could be resolved and be other family member
210cc deficient. members. prevented. increase the intake of
Urinalysis: (Nursings Pocket guide, 7. Discussing this with the patient water.
yellow, Dehydration, which Marilynn E. Doenges, and the patients family
cloudy urine shows in the urinalysis pp.253) members helps them
loosing a yellow, cloudy urine, understand the importance of
liquid stool less saliva formation oral intake of fluids especially
at least 3x a and dry lips. water.
day for 3 Source: (Nursings Pocket guide, Marilynn
days already http://en.wikipedia.or E. Doenges, pp. 253 )
g/wiki/ fluids/
 Cues/ Needs Nursing Rationale Goal and Interventions Rationale Evaluation
diagnosis Objectives
Subjective Data: Acute AGE (Acute After a INDEPENDENT: INDEPENDENT: After a day of
Iiyak siya kapag pain on the Gastro day of 1. Note location of pain 1. Locating it can help less the pressure nursing
sumsakit yung tiyan abdominal Enteritis) nursing 2. Instruct client to notify applied to that area. intervention the
nya tapos sasabihin area intervention nurse immediately when 2. Noting the pain can help take note if goal is partially
niya na tae ako related to Diarrhea the patient: abdominal pain occurs. his condition is worsening. met by the patient
ibig sabihin nun hyperactive 3. Perform pain assessment 3. To rule out worsening of underlying as manifested by:
natate na siya as bowel Symptoms are 1. Verbaliz each time pain occurs. Note conditions and development of 1. Less facial
verbalized by the move- abdominal ed and investigate changes from complications. grimace. The
clients family ments pain and controll previous reports 4. Pain is a subjective experience and patient
members secondary hyperactive ed 4. Asses the clients cannot be felt by others. doesnt react
to AGE bowel feeling description of pain. 5. Observations may or may not be to much. The
Objective Data: (Acute movements of pain 5. Observe the nonverbal congruent with verbal reports indicating just plays with
Facial grimace is Gastro 2. Be cues and other objective. need for further evaluation. the stet while
seen when Enteritis). SOURCE: relieved 6. Asses for the referred pain 6. To help determine possibility of the nurse
saying the word Scott-Conner from as appropriate. underlying conditioned. assess him
Tae ako CEH Brunson the 7. Work with client related 7. Timely intervention is more likely to again.
Facial grimace is Surgery and reporte to pain. be successful in alleviating pain. 2. There is pain
seen when Anesthesia. in d pain 8. Maintain quiet, 8. It provides a nonpharmacological when he
palpates the Basic 3. Able to comfortable environment; pain management. Mental or emotional needs to
abdomen Principles and sleep restrict visitors as necessary. stress increases pressure on the incision defecate.
especially on the Clinical and rest 9. Provide adequate rest and pain felt by the patient. 3. The patient
left upper Practice with periods. 9. To prevent fatigue. can sleep
quadrant. Embury SH, less pain continuously
Hyperactive Hebbel RP, 4. Absence INTERDEPENDENT: INTERDEPENDENT: only if he feels
bowel sounds on Mohandas N, of Facial 1. Apply warm/cold compress 1. Ice Therapy significantly reduces the to defecate
the abdomen Steinberg MH Grimace as ordered by the amt of analgesic medication reqd. again, he got
especially on the eds. Raven physician. Warm compress increases blood flow irritated.
left upper Press NewYork o the area and contributes to pain 4. There is less
quadrant. 1994. pp.809- (Nursing Care Plan Edition 7 by reduction. facial grimace.
827. Doenges, Moorhouse and (Nursing Care Plan Edition 7 by Doenges,
Murr, page 65-66) Moorhouse and Murr, page 65-66)