Nursing Care Plan 1: Imbalanced nutrition: more than body requirements related to use of food as coping mechanism

ASSESSMENT NURSING PROBLEM NURSING RATIONALE EVALUATION

DIAGNOSIS STATEMENT/ GOAL
INTERVENTIO
N

Imbalanced Independent:
Subjective: nutrition: more than Within one (1) hour of After (1) hour of intervention
body requirements nursing intervention, ● Determine ● Weight the client verbalized:
“Napapalakas kain ko related to use of food the client will be able weight, needs to be
ngayong ikalawang to: waist documented ● Acceptance of
as coping mechanism
pagbubuntis ko, circumfere objectively, adopting lifestyle
madalas dalawa change.
Short term: nce, and as the
hanggang tatlong tasa body mass patient may ● appropriate selection
ng kanin ang kinakain index have been of meals or menu
● verbalize
ko” As verbalized by (BMI) only plan towards weight
acceptance of
the patient. estimating management.
adopting lifestyle
over time. ● Stress reduction
change.
● Assess the management as
● To raise the
effects or ● Medical alternatives to
Objective: client’s
complicati complicatio eating.
awareness
ons of ns include ● awareness regarding
regarding her
being cardiovascul her unhealthy
unhealthy
overweigh ar and lifestyle in excessive
Bodyweight- 174 lifestyle in
pounds t. respiratory dietary intake.
excessive
dysfunction, ● The importance of
dietary intake. sleep -
Weight gain - 20 lbs dietary
● Patient will disordered modifications to
verbalizes breathing, meet individual
 appropriate higher long-term goals of
BMI - 29.4 selection of incidence of weight control, using
meals or menu . diabetes principles of variety,
Vital signs: mellitus, and
planning balance, and
towards weight aggravation moderation
● BP - 130/80 of
● PR - 80 management.
● Patients will musculoskel
beats/minute etal
● RR- 18 verbalize stress
disorder,
breaths/minute reduction
social
● Temperature - management as
complicatio
36.9 °C . alternatives to ns and poor
eating. self- esteem
may also
Long Term: result from
obesity.
● Patient will
understand the
dietary
modifications to Perform a
nutritional ● Environmen
meet individual
assessment to tal factors
long-term goals
include: contribute to
of weight
● Daily food overweight
control, using more than
principles of intake-
type and genetics or
variety, balance, biological
amount of
and moderation. vulnerability
food.
● Approxim .
● Assessment
ate caloric
intake. of current
● Activity at eating
time of patterns
 eating. provides a
● Feelings baseline for
at time of change.
eating.
● Location
of meals.
● Meals
skipped.
● Snacking
patterns.
● Social/
Family
considerat
ions.
● Overeating
● Determine may be
the triggered by
behavioral environment
factors al cues and
that behavioral
contribute factors
to unrelated to
overeating physiologica
. l hunger
sensations.

● Food labels
● Assess contain
the information
patient’s necessary in
ability to making
read food appropriate
labels. selections,
 but can be
misleading.
Patients
need to
understand
that “low -
fat” or “fat
free” does
not mean
that a food
item is
calorie free.

● This
● Assess the information
patients provides the
ability to starting
plan a point for the
menu and educational
make sessions.
appropriat Teaching
e food content the
selections. patient
already
knows
wastes
valuable
time and
hinders
critical
learning.
● Serving
sizes must
● Assess the be
patient's understood
ability to to limit
accurately intake
identify according to
appropriat a planned
e food diet.
portions.
● Memory is
● Encourage inadequate
the patient for
to keep a quantificatio
daily log n for intake,
of food or and a visual
liquid record may
ingestion also help the
and patient make
caloric more
intake. appropriate
food choices
and
servicing
sizes.

● This care
plan
● For
provides
patients
information
ready to
on strategies
engage in
for engaging
a serious
in a
weight
successful
manageme
weight
 nt management
program, program.
refer to
the care
plan:
Readiness
for weight
manageme
nt.

● Patients
● Review need to be
the aware of
complicati long - term
on health
associated problem as a
with stimulus for
obesity. change.

● The patient
● Teach need to
stress substitute
reduction healthy for
methods unhealthy
as behavior.
alternative
s to
eating.

Dendent:
Dependent: ● Change in
eating
● Consult a patterns are
dietician required for
for further weight
assessmen management
t and . The type of
recommen program
dation may vary
regarding (e.g, three
a weight balanced
manageme meals a day,
nt avoidance of
program. certain high
- fat foods.)
Dietitians
have a
greater
understandin
g of the
nutritional
value of
foods and
may be
helpful in
assessing or
substituting
specific high
- fat cultural
or ethnic
foods.
 Nursing Care Plan 2: Fatigue related to pregnancy as evidenced by tiredness, apathy, lack of concentration and ineffective role
performance.

ASSESSMENT NURSING PROBLEM NURSING RATIONALE EVALUATION

DIAGNOSIS STATEMENT/GO INTERVENTÍON
AL

Subjective: Fatigue related Independent After one (1) hour

to pregnancy as Within one (1) hour of nursing
● “Di ko alam pero evidenced by of nursing ● Assess the ● Specific intervention the
bakit ang dali apathy and intervention, the patient’s information patient has
client will be able about the
kong napapagod, ineffective role description verbalized
to: patient
ibang-iba sa dati performance of fatigue experiencing
reduction of fatigue
kong (afternoon fatigue can as evidenced by
pagbubuntis na Short Term: versus all reported improved
help them
di naman ako day), develop an sense of energy and
masyadong ● The patient severity, identify the basis of
individual
napapagod” as verbalizes relationships approach. fatigue and
stated by the reduction of to activities Quantitative individual areas of
patient. fatigue as and rating scale control.
evidenced aggravating (e.g., 0 to 10)
by reported factors. Can help the The patient
improved patient
verbalized and
sense of describe the
amount of
demonstrate health
Objective: energy. teaching to perform
● Identify the fatigued
experience. activities of daily
● Apathy basis of living and
● Lack of fatigue and participate in
concentration individual desired activities at
● Tiredness areas of level of ability.
● Ineffective role control. Assess for possible ● Identifying
performance causes of fatigue, related
factors can
 such as: aid in
Long Term determining
● Physical possible
● The patient illness causes and
will be able ● Emotional establishing
verbalize stress a
and ● Medication collaborativ
demonstrate side effects e care plan.
health ● Sleep
teaching to disorder
perform ● Imbalanced
activities of nutritional
daily living intake.
and ● Increased
participate responsibilit
in desired ies and
activities at demands at
level of home or
ability. work.
● Fatigue can
● Assess the limit the
patient’s patient’s
ability to ability to
perform participate
ALDs, in self care
instrumental and perform
activities of her role
daily living responsibilit
(LADs), and ies.
demands of
daily living
(DDLs).
 ● Assess the ● Fatigue is a
patient’s very
emotional distressing
response to symptom
fatigue that
significantly
affects
quality of
life. These
emotional
states can
add to the
patient’s
fatigue level
and create a
vicious
cycle.
.
● Fatigue may
● Evaluate the be a
patient’s medication
routine side effect
prescriptions or indication
and over - of a drug
the counter interaction.
medication.
● Fatigue may
● Assess the be a
patient’s symptom of
nutritional protein -
intake of calorie
calories, malnutrition
protein, , vitamin
minerals, deficiences,
and or iron
vitamins. deficiency.

● Changes in
● Evaluate the the patient's
patient’s sleep pattern
sleep pattern may be a
for quality, contributing
quantity, factor in the
time taken developmen
to fall t of fatigue.
asleep, and
feeling on
awakening.
Also assess
for sleep
apnea.
● Increased
● Assess the physical
patient’s exertion and
usual level limited
of exercise levels of
and physical exercise can
activity. contribute to
fatigue.
 ● Recognizing
● Encourage relationships
the patient’s between
to keep 24 - specific
hour fatigue activities
and activity and levels of
at least 1 fatigue can
week. help the
patient
identify
excessive
energy
expenditure.
The log may
indicate
times of day
when the
patient is the
least
fatigued.

● A plan that
● Assist the balances
patient with periods of
developing a activity with
schedule for periods of
daily rest can help
activity and the patient
rest. Stress complete
the desired
importance activities
of frequent without
rest periods. adding
 levels of
fatigue.

● The use of
Implement the use assistive
of assistive and devices can
adaptive devices for minimize
ADLs, and LADs. energy
expenditure
● long - and prevent
handled injury with
sponge for activities.
bathing
● Sock - puller
● Long - ● Setting
handled priorities is
grabber. one example
of an energy
-
conservation
● Assist the technique
patient’s that allows
with setting the patient
priorities for to use
desired available
activities energy to
and role accomplish
responsibilit important
ies and activities.
refraining Achieving
from desired
performing goals can
 activities. improve the
patient’s
mood and
sense of
emotional
well - being.

● The patient
will need
properly
balanced
intake of
fats,
● Promote carbohydrat
adequate es, protein,
nutritional vitamins,
intake. and minerals
to provide
energy
resources.

● Promoting
relaxation
before sleep
and
providing
for several
hours of
● Help the uninterrupte
patients d sleep can
develop contribute to
habits to energy
promote restoration.
 effective
rest/sleep
patterns.

Dependent:
● Patients and
● Teach caregivers
energy - may need to
conservation learn skills
techniques. for delegating
Refer to task to others,
occupational setting
priorities, and
times for
clustering
rest and care to use
sleep. available
energy to
● Encourage complete
an exercise desired
conditioning activities.
program as The
appropiate. occupational
therapist can
reinforce
energy -
conservation
techniques
and provide
the patient
with assistive
devices as
needed.
Nursing Care Plan 3: Deficient fluid volume related to inability to resist thirst reflex as evidence by increase urine output

ASSESSMENT NURSING PROBLEM NURSING RATIONALE EVALUATION

DIAGNOSIS STATEMENT/GOA INTERVENTÍON
L
 Independent ● After the
Subjective: Risk for Deficient After nursing nursing
“Napapansin ko na fluid volume related intervention, the client ● Monitor ● A decrease in interventio
nakakaramdam ako ng to inability to resist will be able to: and circulating n the client
pagka - uhaw palagi kaya thirst reflex as ● Understand document blood volume reports
lagi din ako umiihi” as evidence by increase that can cause awareness
vital signs,
stated by the client. urine output maintaining hypotension that
fluid volume
especially and maintaining
at functional BP and HR tachycardia. fluid
Objective : level is Alteration in volume at a
important , as HR is a functional
● Poor skin turgor evidenced by compensator level is
● Dry mucous individually y mechanism important,
membrane adequate to maintain resulting in
● Increases urine urinary , cardiac individuall
output stable vital output. y adequate
signs , moist urinary ,
mucous ● Monitor ● Measurement stable vital
membrane , fluid intake of the client’s signs ,
good skin and output intake and moist
turgor . output is first mucous
measured by membrane ,
● verbal the nurse and and good
understanding evaluated for skin turgor.
of causative at least at 8- ○
factors and hour intervals ● After the
purpose of is the first nursing
individual step to interventio
therapeutic assessing the n the client
interventions presence of verbalize
and hypovolemia. causative
medications . factors and
● Normal urine purpose of
● Assess color output is individual
and amount considered therapeutic
of urine. normal, not interventio
Report urine less than ns and
output less 30ml/hour. medication
than 30 Concentrated s.
ml/hr for urine denotes
two (2) fluid deficit.
consecutive
hours.
● Febrile states
● Monitor and decrease
document body fluids
temperature. by
perspiration
and increased
respiration.
This is
known as
insensible
water loss.

● Most fluid
● Monitor comes into
fluid status the body
in relation to through
dietary drinking,
intake. water in food,
and water
formed by
the oxidation
of foods.
Verifying if
 the patient is
on a fluid
restraint is
necessary.

● These factors
influence
● Note the intake, fluid
presence of needs, and
nausea, route of
vomiting, replacement.
and fever.
● Weight is the
best
● Weigh daily assessment
with the data for
same scale, possible fluid
and volume
preferably at imbalance.
the same An increase
time of day. in 2 lbs a
week is
considered
normal.

● Establishing
a database of
● Identify the history aids
possible accurate and
cause of the individualize
fluid d care for
disturbance each patient.
or
 imbalance. ● Early
detection of
● Monitor for risk factors
the existence and early
of factors intervention
causing can decrease
deficient the
fluid volume occurrence
(e.g., and severity
gastrointesti of
nal losses, complication
difficulty s from
maintaining deficient
oral intake, fluid volume.
fever, The
uncontrolled gastrointestin
type II al system is a
diabetes common site
mellitus, of abnormal
diuretic fluid loss.
therapy).
● A patient
● Encourage may have
them to restricted oral
drink intake in an
bountiful attempt to
amounts of control
fluid as urinary
tolerated or symptoms,
based on reducing
individual homeostatic
needs. reserves and
increasing the
 risk of
dehydration
or
hypovolemia.

● Increasing
● Emphasize the patient’s
the knowledge
relevance of level will
maintaining assist in
proper preventing
nutrition and and
hydration. managing the
problem.

● An accurate
● Teach family measure of
members how fluid intake
to monitor and output is
output in the an important
home. indicator of a
Instruct them
patient’s fluid
to monitor
both intake status.
and output.

● Emphasize ● A fluid
the deficit can
importance cause a dry,
of oral sticky mouth.
hygiene. Attention to
mouth care
promotes
interest in
 drinking and
reduces the
discomfort of
dry mucous
membranes.

Dependent:

●
●
Nursing Care Plan 4: Modere Anxiety related to changes in health status as evidenced by emotional tension and worriedness.

ASSESSMENT NURSING PROBLEM NURSING RATIONALE EVALUATION

DIAGNOSIS STATEMENT/GO INTERVENTÍON
AL
 Modere Anxiety Independent: After (45)
Subjective: related to Within one (45) minutes of
changes in minutes of nursing nursing
“Nung nalaman ko na health status as intervention, the ● Establish a ● Establishes intervention the
may diabetes yung client will be able therapeutic rapport,
evidenced by client appeared
to: relationship, promotes
tatay ko katulad ng lola emotional relaxed and the
rapport, be expression of
ko nag-alala ako sa tension and available for feelings, and anxiety was
kalagayan ng tatay ko worriedness. Short Term: reduced to a
listening and helps clients
at na te-tense ako sa talking. look at realities manageable level
mga nangyari baka ● Appear and reported
of the illness or
posible na magkaroon relaxed and treatment awareness of
din ako.” as verbalized report that without feelings of
by the client. anxiety is confronting anxiety.
reduced to a issues they are
manageable not ready to The patients have
level deal with. also identified
Objective : ● Verbalize and demonstrated
awareness ● Assess the ● The patient with
patient's level mild anxiety healthy ways to
● Tense and lack of feelings deal with and
of anxiety. of anxiety will have
of period minimal or no express anxiety.
concentration. physiological
Long Term:
● Frustrated symptoms of
● Confused ● Identify anxiety . vital
signs will be
healthy within normal
ways to deal ranges period
with and the patient will
express appear calm
anxiety. but may report
feeling of
nervousness.

● Understanding
● Identify the the client point
 client’s of view
perception of promotes a
the threat more accurate
represented plan of care.
by the
situation.
● To identify
● Monitor vital physical
signs responses
associated with
both medical
and emotional
conditions.

● Interviewing the
● Determine patient helps
how the determine the
patient uses effectiveness of
coping coping
strategies and strategies
defense currently used
mechanisms by the period.
to cope with
anxiety.

● Because a cause
for anxiety
● Acknowledge cannot always
awareness of be identified,
the patient's the patient may
anxiety. feel As though
the feeling
being
experienced are
counterfeit.
 Acknowledgem
ent of the
patient's
feelings
validates the
feelings and
communicates
acceptance of
those feelings.

● The healthcare
provider can
● Maintain a transmit his or
manner while her own anxiety
interacting to the
with the hypertensive
patient . patient . the
patient's feeling
of stability
increases in a
calm and non
threatening
atmosphere .

● This helps the

client identify
● Provide what is reality
accurate based.
information
about the
situation.

● Orientation to
an awareness of
● Orient the the
patient surroundings
environment promotes
and new comfort and
experiences may decrease
or people as anxiety
needed . experienced by
the patient.

● When
experiencing
● Use simple moderate to
language and severe anxiety ,
brief patients may be
statements unable to
when comprehend
instructing anything more
the patient than simple ,
about self clear , and brief
care instruction .
measures or
about
diagnostic
and surgical
procedures.

● Anxiety may
escalate to a
● Reduce panic state with
sensory excessive
stimuli by conversation ,
maintaining a noise , and
quiet equipment
environment, around the
keep patient.
“ threaten” Increased
 out of sight. anxiety may
become
frightening to
the patient to
others.

● Talk about
anxiety
● Encourage producing
the patient to situations and
talk about anxious feelings
anxious can help the
Feelings and patient perceive
examine the situation
anxiety- realistically.
provoking Unrecognized
situations if factors leading
they are to the anxious
identifiable . feeling .

● Recognition and
exploration of
● Suggest that factors leading
the patient to reducing
keep a log of anxious feelings
episodes of are important
anxiety . steps in
instruct the developing
patient to alternative
describe what responses.
is experience
and the
events
leading up to
and
 surrounding
the event . the
patient
should note
how density
dissipates.
● Determining
coping skills
used in the past
● Support the might be
patient's use helpful in
of coping current
strategies that circumstances.
the patient
has found
effective in
the past. ● Learning new
coping methods
provides the
● Assist the patient with a
patient in variety of ways
developing to manage
new anxiety- anxiety.
reducing
skills (e.g.,
relaxation,
deep
breathing,
positive
visualization
and
prayer/medita
tion.) ● Learning to
identify a
● Assist the problem and to
patient in evaluate the
 developing alternatives to
problem- resolve that
solving problem help
abilities . size the patient cope.
the logical
strategies that
the patient
can use when
experiencing
anxious ● Short term use
feelings. of antianxiety
medication can
● Instruct the enhance patient
patient in coping and
appropriate reduce
use of physiological
antianxiety manifestation of
medications. anxiety.

● The patient will

be able to use
problem solving
● Assist the abilities more
patient in effectively
recognizing when the level
symptoms of of anxiety is
increasing low .
anxiety , knowledge of
explore anxiety and
alternatives effective coping
to use to strategies can
 prevent the help the
anxiety from patient's
immobilizing feelings of
him or her . control over
anxiety
producing
situations.

● Cognitive
Appraisal of
mild or mild
● Remind the anxiety Can
patient that help the patient
anxiety at a perceive the
mild level anxiety As an
can opportunity to
encourage develop new
growth and strength that
development enhances
and is coping.
important in
mobilizing
changes.

● Additional ,
long-term
professional
● Refer the care may be
patient for needed when
psychiatric anxiety
management becomes severe
of anxiety and interferes
that becomes with daily
disabling for functioning .
an extended The types of
period. disorder
 requiring this
level of care
include panic
disorders ,
obsessive-
compulsive
disorder , and
post traumatic
stress disorder.

● Long term
Dependent: professional
care may be
● Refer the needed when
patient for anxiety
psychiatric becomes severe
management and interferes
of anxiety with daily
that becomes functioning.
disabling for
an extended
period.