NURSING CARE PLANS

CUES NURSING RATIONALE NURSING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS GOAL
Subjective: Bacteria that After 8 hours of Independent: • The goal was met
Fluid Volume are present in nursing as evidenced by:
“Matubig yung Deficit related the body adhere interventions, • Observe and •Helps
dumi niya, to frequent to mucosa to the patient will record stool differentiate a. Reduction in
madalas din passage of avoid being maintain frequency, individual disease frequency of
siyang watery stool swept away adequate fluid characteristics, and assess severity stools (1x per
magsuka” as and vomiting. then binds to volume as amount and of episode. shift)
verbalized by the receptors on evidenced by precipitating b. No vomiting
patient’s the intestinal factors. c. Moist mucous
guardian. surfaces. a. Reducti membrane.
Mucosal on in • Promote bed rest. • Rest decreases d. Good skin
Objective: adherence frequency of intestinal motility turgor
• Frequent causes changes watery and reduces
watery stools to the gut stools. metabolic rate.
with foul smell epithelium that b. (-)
(2-3x per shift). may reduce its vomiting • Identify foods • Avoiding
absorptive c.Moist and fluids that intestinal irritants
• (+) capacity or mucous precipitate promotes
vomiting (2x cause fluid membrane diarrhea. intestinal rest.
day) secretion. d. Good skin
• Sunken turgor • Encourage to eat • Fruits that are
anterior foods like stool former.
fontanel latundan banana
• Weak- and apple.
looking
• Irritable • Teach significant • To prevent
• Dry others how to recurrence of the
mucous properly feed the disease.
membrane patient and give
 some
precautionary
measures.

• Weigh daily. • Indicator

of overall
fluid and
nutritional
status.
Collaborative:
• To prevent
• Replace
further
Fluid losses
dehydration.
volume per
volume.
• To help prevent
proliferation of
• Administer
bacteria.
medications as
prescribed by the
physician.
 CUES NURSING RATIONALE NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS GOAL
Subjective: Hyperthermia The systemic After 4 hrs. Of Independent: After 4 hrs. Of
“Mainit na naman related to inflammatory nursing nursing
siya, may lagnat presence of response interventions, • Monitor body • To have a interventions, the
ba?” as verbalized infection. syndrome is the patient will temperature, heart baseline data patient was able
by the patient’s characterized by maintain core rate and rhythm. regarding the maintain core
guardian. synthesis and temperature onset of fever and temperature within
release of within normal note other direct normal range and
Objective: pyrogenic range, be free effect of fever in free from chills.
• Flushed skin, cytokines from a from chills. cardiac tissues.
warm to touch. variety of cells.
• Restless These cytokines, • Promote surface • To decrease
• Irritable in turn, trigger cooling by means of temperature by
• Teary eyed specialized tepid sponge bath. means through
• Chills noted endothelial cells evaporation and
• Tachycardia of the conduction.
hypothalamic
• V/S taken as vascular organs, • Monitor • Room
follows: resulting in a environmental temperature/num
T: 39.3 ˚C resetting of the temperature/limit ber of blankets
P: 156 bpm hypothalamic or add linen as should be altered
R: 37 cpm thermostat from indicated. to maintain near
BP: 100/60 normothermic to body
mmHg febrile levels. temperature.

• Maintain bed rest. • To reduce

metabolic
demands and
oxygen
consumption
Collaborative:

• Administer • To facilitate fast

antipyretics orally recovery.
or rectally as
prescribed by the
physician.

• Administer • To support
replacement circulating
fluids and volume and
electrolytes tissue perfusion.
 CUES NURSING RATIONALE NURSING NURSING RATIONALE EVALUATION
DIAGNOSIS GOAL INTERVENTION

Subjective: Impaired Skin The rash is After 1-2 days Independent The goal was
Integrity due to caused by of nursing met as evidenced
“Bakit may mga presence of small blood intervention, the • Assess patient • To determine by absence of
pantal siya sa vessels in the skin thoroughly. if rashes
katawan”, as rashes. patient will have rashes.
skin leaking developed in
patient’s blood into the improved skin other parts of
guardian tissues, where integrity as the body.
verbalized. the blood forms evidenced by
a small red reduction of • Maintain strict • To maintain
Objective: patch with rashes. hygiene. skin integrity at
irregular shape optimal level.
• Presence of but quite sharp
maculo- edges. As the • Monitor • Clotting
papular rash color is from laboratory factors may
on truck and red blood cells results pertinent show abnormal
lower that are unable to causative result that may
to move, factors. increase the
extremities.
pressing on the patient risk.
• (+) LATS skin does not
change their • Promote • Rashes may
color. patient’s cause itchiness.
comfort.

Collaborative

• Give • To relieve
medications as any discomfort.
prescribed.