Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar
COLLEGE of NURSING and ALLIED HEALTH SCIENCES
NURSING CARE PLAN
Name of Patient:_______________--Date Admitted: Chief Complaint: __________________ Case Number: __________
Age: ______Gender: ____________Civil Status: ___________ Address: ___________________-Ward:_____________
ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/PLANNING NURSING SCIENTIFIC EVALUATION
DIAGNOSIS RATIONALE INTERVENTIONS RATIONALE
Subjective: Fluid volume deficit Fluid Volume After 6 hours of Nursing Monitor early sign Early detection of After 6 hours of
“Tubigan an related to diarrhea as Deficit (FVD), Intervention, the patient will be and symptoms of fluid fluid deficit helps to Nursing
akpon uro” as evidenced by watery hypovolemia) is a able to: volume deficit like replenish adequate Intervention, the
stated stools more than 3 state or condition decreases skin turgor, fluid in the body. patient is able to:
times/day. where the fluid 1. Patient is normovolemic as dry mucus membrane,
output exceeds the evidenced by systolic BP and urine specific Patient is
fluid intake. It greater than or equal to 90 normovolemic as
gravity >1.025. The antidiarrheal
Objectives: occurs when the mm HG (or patient’s evidenced by
body loses both baseline), absence of drug decreases systolic BP greater
(+) watery stools water and orthostasis, HR 60 to 100 peristaltic than or equal to 90
(+) Cellulitis electrolytes from beats/min, urine output Administer fluid movement. mm HG (or patient’s
Right Foot the ECF in similar greater than 30 mL/hr and parenterally and baseline), absence of
(+) Cough proportions. normal skin turgor. provide the orthostasis, HR 60 to
Common sources of antidiarrheal drugs as Increase fluid intake 100 beats/min, urine
BP: 160/120 fluid loss are the 2. Patient demonstrates per prescription. replenish the fluid output greater than
gastrointestinal lifestyle changes to avoid 30 mL/hr and norma
deficit in the body
tract, polyuria, and progression of skin turgor.
and prevent
increased dehydration.
perspiration. Risk Encourage the patient dehydration. Patient demonstrated
factors for deficient 3. Patient verbalizes to take at least lifestyle changes to
fluid volume are as awareness of causative 1500ml to 2000ml of avoid progression of
follows: vomiting, factors and behaviors fluid plus 200ml for dehydration.
diarrhea, GI essential to correct fluid each loose stool.
suctioning, deficit. It increases gastric Patient verbalized
sweating, decreased 4. Patient explains measures mucosal motility. awareness of
intake, nausea, that can be taken to treat or Instruct the patient to causative factors and
inability to gain prevent fluid volume loss. avoid caffeine and behaviors essential
access to fluids, alcoholic beverages. to correct fluid
adrenal 5. Patient describes deficit.
insufficiency, symptoms that indicate the To prevent
osmotic diuresis, need to consult with health Monitor intake and dehydration. Patient explained
hemorrhage, coma, care provider. measures that can be
output. Keep in mind
third-space fluid taken to treat or
that intake should be
shifts, burns, prevent fluid volume
ascites, and liver greater than the loss.
dysfunction output.
It determines the
fluid loss from the Patient described the
body. symptoms that
indicate the need to
consult with health
care provider.
ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/PLANNING NURSING SCIENTIFIC EVALUATION
DIAGNOSIS RATIONALE INTERVENTIONS RATIONALE
Subjective: “nag Acute pain related to Abdominal pain After 4hours of nursing Encourage the patient It promotes GI After 4hours of
parasuol akon abdominal cramping may include intervention the patient will be to remain in the muscle relaxation, nursing intervention
tiyan” as stated and diarrhea, as conditions like able to: supine position and thereby reduces the patient is able to
reported by the patient. irritable bowel keep a warm heating abdominal cramps.
syndrome, 1. The patient will report pad on the abdomen. 1. The patient
gastroenteritis, and abdominal pain of 2/10 or reported
constipation. More less by discharge abdominal pain
serious causes of It makes patients of 2/10 or less
Objectives: abdominal pain 2. The patient will report Eliminate unpleasant less irritable and by discharge
PRS: 6/10 include relief from nausea, odour in the room of provides mental
(+) watery stools appendicitis, cramping, gas, etc., by the client. An relaxation. 2. The patient
(+) Cellulitis cholecystitis, discharge aromatic incense stick reported relief
Right Foot endometriosis, or aromatic spray can from nausea,
(+) Cough cancer, bowel To reduce pain. cramping, gas,
be sprayed in the
obstruction, room. etc., by
BP: 160/120 gallstones, kidney It can induce discharge
stones, and pelvic abdominal cramping
inflammatory
disease. Protect the perianal
area from injury and Analgesics and
sedatives are
irritation.
provided for pain
management and
Teach the client to relief. Medications
avoid very hot or cold to relieve gas,
liquid or food. nausea, constipation,
and diarrhea may
also relieve pain.
Provide medications
as ordered.
ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/PLANNING NURSING SCIENTIFIC EVALUATION
DIAGNOSIS RATIONALE INTERVENTIONS RATIONALE
Subjective: Deficient Knowledge The focus of After 20 minutes of nursing Explain that long- Long-acting insulin After 20 minutes of
“nahubag ak related to unfamiliarity diabetes education interventions the patient will be acting insulin does not have a peak nursing intervention
luyo na siki” as with insulin injection should be patient able to: (Lantus) only need to of action. Insulin the patient will be
stated. empowerment to be injected once or glargine is effective able to:
address changes in 1. Patient will demonstrate twice daily. for over 24 hours.
health behavior and knowledge of insulin 1. Patient
self-care. Providing injection, symptoms, and .Explain that regular Dosage may be demonstrated
complete prandial insulins adjusted based on knowledge of
information and
treatment of hypoglycemia (Humulin) should be the amount of food
Objectives: proper education to and diet. injected 30 mins ingested because
insulin injection,
PRS: 6/10 patients with before meals. Rapid- rapid-acting insulins symptoms, and
(+) watery stools diabetes can acting insulins can be given after a treatment of
(+) Cellulitis dramatically (Novolog, Humalog) meal. hypoglycemia and
Right Foot increase adherence may be injected diet.
(+) Cough to the treatment before or after eating. Insulin dosage
regimen. should be reduced
BP: 160/120 . Explain that insulin when fasting for
dosages may need to surgery, when not
be adjusted. eating, or when
hypoglycemia
occurs. Illness or
Teach the patient to infection may
rotate insulin injection increase insulin
sites. requirements.
Explain the Systematic rotation
importance of of injection sites is
inserting the needle recommended to
perpendicular to the prevent
skin. lipodystrophy.
Teach the patient to
follow a low in simple A 90-degree angle is
sugars, low in fat, and the best insertion
high in fiber and angle because this
whole grains. ensures deep
subcutaneous
Teach the patient administration of
and/or SO to insulin. An injection
recognize the signs of that is too deep or
hypoglycemia. too shallow may
affect the rate of
Provide written absorption of the
information about insulin.
diabetes management
for the patient to refer A diet low in fat and
to. high in fiber helps to
control cholesterol
and triglycerides.
Three daily meals
and an evening
snack are
recommended.
Refined and simple
sugars should be
reduced, and
complex
carbohydrates, such
as cereals, rice
should be increased.
Signs include
shakiness, sweating,
nervousness,
weakness, hunger,
changes in LOC.
Hypoglycemia
occurs when the
blood glucose levels
drop to less than 60
mg/dL. Explain that
hypoglycemia
occurs when too
much insulin, too
little food, too much
oral hypoglycemic
agents, or excessive
physical activity.
Reinforces learning
and conveys the
maximum amount of
information.
ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/PLANNING NURSING SCIENTIFIC EVALUATION
DIAGNOSIS RATIONALE INTERVENTIONS RATIONALE
Subjective: “ Imbalanced Nutrition: Nutrition plays an After 8 hours of nursing Review the Carbohydrate After 8 hours of
nakakadamo ak Less Than Body important role in the intervention the patient will be carbohydrate counting involves nursing intervention
ihi permi ” as Requirements related to management and able to: counting method counting the number the patient is able to
stated. Insulin deficiency as treatment of Patient will ingest appropriate with the patient. of grams of
evidenced by Increased diabetes. Diabetes amounts of calories/nutrients. carbohydrate in a Patient ingested
urinary outpu requires a balance meal and matching appropriate amounts
between the intake Patient will display usual that to your dose of of calories/nutrients.
of nutrients, energy level. Identify food insulin.
Objectives: expenditure of preferences, Patient displayed
PRS: 6/10 energy, and timing Patient will demonstrate including ethnic and usual energy level.
(+) watery stools and dose of insulin stabilized weight or gain cultural needs. If the patient’s food
(+) Cellulitis or oral antidiabetic toward usual/desired range with preferences can be Patient demonstrated
Right Foot agents. normal laboratory values. incorporated into the stabilized weight or
(+) Cough Observe for signs of meal plan, gain toward
hypoglycemia: cooperation with usual/desired range
BP: 160/120 dietary requirements with normal
changes in LOC,
cold and clammy may be facilitated laboratory values.
skin, rapid pulse, after discharge.
hunger, irritability,
Hypoglycemia can
anxiety, headache,
occur once blood
lightheadedness,
glucose level is
shakiness.
reduced,
carbohydrate
metabolism resumes,
and insulin is given.
Educate the patient If the patient is
on the dangers of comatose,
consumption of hypoglycemia may
alcohol with diabetes occur without a
mellitus. notable change in
LOC
Similar alcohol
consumption
precautions by
people without
diabetes apply to
people with
diabetes. When
consumed, alcohol is
absorbed first before
other nutrients.
ASSESSMENT NURSING SCIENTIFIC OBJECTIVES/PLANNING NURSING SCIENTIFIC EVALUATION
DIAGNOSIS RATIONALE INTERVENTIONS RATIONALE
Subjective: Fatigue related to Fatigue is a After 6 hours of nursing Discuss with the Education may After 6 hours of
“Maluyahon Altered body chemistry: common complaint intervention the patient will be patient the need for motivate to increase nursing intervention
naak gud mag insufficient insulin as distressing people able to: activity. Plan schedule activity level even the patient is able to
kiwa kiwa” as evidenced by decreased with diabetes and with the patient and though the patient
stated performance can likely affect The patient will verbalize identify activities that may feel too weak The patient
their daily activities increase in energy level. lead to fatigue. initially. verbalized increase
and self-care in energy level.
towards diabetes The patient will display To prevent excessive
management and improved ability to participate Alternate activity with fatigue. The patient
treatment. in desired activities. periods of rest and displayed improved
Objectives: uninterrupted sleep. The patient will be
ability to participate
PRS: 6/10 able to accomplish
in desired activities.
(+) watery stools more with a
(+) Cellulitis decreased
Right Foot Discuss ways of expenditure of
(+) Cough conserving energy energy.
(+) Facial while bathing,
Grimace transferring, and so Increases confidence
on. level, self-esteem,
BP: 160/120 and tolerance level
Increase patient Prevents excessive
participation in ADLs fatigue. Indicates
as tolerated. physiological levels
of tolerance.
Alternate activity with Interventions should
periods of rest or be directed at
uninterrupted sleep. delaying the onset of
fatigue and
optimizing muscle
Perform activities efficiency.
slowly with frequent
rest periods. For proper
oxygenation.
Helps promote
Provide adequate relaxation.
ventilation.
To be free from
injury during
Instruct the patient to activity.
perform deep
breathing exercises.
Provide comfort and
safety measures.
