NURSING CARE PLAN

DATE/TIME NURSING OBJECTIVE/OUTCOME NURSING NURSING DATE/ EVALUAT SIGN

DIAGNOSIS CRITERIA ORDERS INTERVENTIONS TIME ION
30/01/2022 Risk for fluid Patient will maintain 1.Reassure 1. Patient and relatives 03/02/22 Goal fully

2:00 pm volume deficit adequate hydration within 4 patient and were reassured that 2:00 pm met as

(dehydration) days as evidenced by; family members dehydration is a sign of evidenced

related to 1. a nurse observing diabetes mellitus type II by;

excessive that patient has a and it can be relieved 1. nurse

urination good skin turgor and with treatment. observing

does not show any that patient

physical sign of 2. Observe 2. Patient was observed has a good

dehydration patient for signs for signs and symptoms skin turgor

2. patient verbalizing and symptoms of of dehydration such as and does

that she has a dehydration. dry mouth, sunken eyes not show

reduction in urine and poor skin turgor any

output and managed physical

accordingly by sign of

administering dehydration
 intravenous fluid such 2. patient

as normal saline. verbalizing

that she has

a reduction

3. The amount of both in urine

3. Monitor and intravenous infusion output

maintain intake and fluid taken in like

and output chart water and amount of

urine passed were

recorded in the intake

and output chart daily

to check for balance or

deficit.

4. Intravenous fluid

4. Administer prescribed for patient

and monitor was administered and

prescribed monitored for number

intravenous of drops per minute and

infusions the site was checked to

prevent any

complication and fluid

overload.

5. Patient was

5. Encourage encouraged to take in

patient to take in enough fluid diet and a

more fluids lot of water to help

prevent dehydration

6. Prescribed

6. Administer medications were

prescribed administered to help

medications prevent the risk of

 dehydration

30/01/2022 Anxiety Patient will be relieved of 1. Reassure 1. Reassure patient that 30/01/22 Goal fully

related to anxiety within 2 hours as patient the disease is 4:00 pm met as

2:00 pm unknown evidenced by; manageable and the evidenced

outcome of staff is ever ready to by;

disease 1. a nurse observing that help in caring for her. 1. a nurse

condition and patient has a cheerful face observing

hospitalization and does not feel anxious 2. Assess and 2. Patient was allowed that patient

anymore clear patient to ask questions and has a

misconception express her concerns cheerful

2. patient verbalizing that about disease and was answered in a face and

she does not feel anxious of simple language she does not

her hospitalization anymore understands in order to feel anxious

clear all fears and anymore

misconceptions 2. patient

verbalizing
 that she

3. Introduce 3. Patient was does not

patient to other introduced to other feel anxious

patients in the patients in the ward of her

ward suffering who were suffering hospitalizati

from the same from the same disease on anymore

disease and are and were doing well to

doing well. relieve her anxiety

4. Inform patient 4. Patient was informed

of availability of of the availability of

equipment and equipment and

competent health competent health

workers workers to care for her

to relieve patient from

 fear and anxiety

5. Explain all 5. All procedures were

procedures to explained to patient and

patient she was encouraged to

ask questions and

answered correctly

30/01/2022 Insomnia Patient will have a normal 1. Assess 1. Patient sleeping 01/02/22 Goal fully

related to sleeping pattern within 48 patient’s pattern was assessed 3:00 pm met as

3:30 pm change of hours as evidenced by: sleeping pattern and was educated on evidenced

environment 1. The nurse observing and educate her the need for her to sleep by;

patient sleeping on the need to 1. The nurse

uninterrupted for at least 6 sleep. observing

hours at night and 2 hours 2. Teach patient 2. Patient was taught patient

during the day. pre-sleep routine pre-sleep routine such sleeping

such as voiding, as voiding, toileting and uninterrupte

2. Patient verbalizing that toileting and bathing to prevent any d for at least

she can sleep well now. bathing interruption during 6 hours at

sleep night and 2

hours

3. Encourage 3. Patient was during the

patient to take a encouraged to take a day.

warm bath warm bath during the 2. Patient

during the night night and a well laid verbalizing

and provide a comfortable bed made that she can

comfortable bed to help patient has a sleep well

for patient to good sleep now

sleep.

4. Provide

adequate 4. Adequate ventilation,

ventilation, dim dim light and a noise

light and a noise free environment was

 free environment provided for her to

for her to induce induce sleep.

sleep.

5. Allow visitors

only during 5. Visitors were

visiting hours. allowed to visit the

patient during visiting

hours only so as not to

interfere with patient’s

resting and sleeping

periods

31/01/2022 Self-care Patient will be able to 1. Reassure 1. Patient and relatives 01/02/22 Goal fully

deficit (bathing maintain her personal patient and were reassured that she 6:00 am met as

6:00 am and grooming) hygienic needs within 24 relatives would be assisted to evidenced

related to manage her personal

general body hours as evidenced by; hygienic needs until she by;

weakness is well to do it on her 1. a nurse

1. a nurse observing that own. observing

patient looks fresh and well that patient

groomed in bed 2. Patient was assisted looks fresh

2. Assist patient to bath twice daily in and well

2. patient verbalizing that to have her bath bed with warm water, groomed in

she looks neat and fresh twice daily. sponge and mild soap to bed

promote comfort and 2. patient

sleep. verbalizing

that she

3. Patient was dressed looks neat

and groomed nicely and fresh

3. Dress and with neat clothing.

groom patient

nicely 4. Soiled bed linen was

changed and bed made

 free from creases and

4. Change soiled crumps.

bed lining

5. Patient was

encouraged to

participate in her self-

5. Encourage care activities to keep

patient to her active. She was

participate in her made comfortable in

self-care bed.

activities as far

as possible.

31/01/2022 Imbalanced Patient will maintain a 1. Reassure 1. She has been 07/02/22 Goal fully

nutrition: less normal nutritional status patient that she reassured that she will 6:00 am met as

6:00 am than body within the period of will be able to be able to eat well in evidenced

requirement hospitalization as evidenced eat well and few hours. by;

related to loss maintain her 1. nurse

of appetite by; normal observing

nutritional that patient

1. nurse observing that status. body weight

patient body weight is is

maintained without 2. Remove all maintained

reducing nauseated item 2. Patient’s bed side without

from the was made free from all reducing

2. patient verbalizing that patient’s bedside nauseated items like 2. patient

she has gain appetite and bedpan and vomitus verbalizing

can now eat two-third of bowl before meal was that she has

food served served to stimulate gain

3. Serve meal patient appetite appetite and

according to the can now eat

patient’s 3. Food was served two-third of

preference. according to patient’s food served

choice of preference in

4. Serve food in order to promote patient

bit at regular appetite

interval. 4. Food was served in

bit at regular interval to

allow patient has

5. Serve well- enough time to swallow

nutritious and food

adequate diet 5. Balanced and

attractively. adequate diet was

served attractively in

order to stimulate

6. Monitor patient appetite

patient weight

daily 6. Patient’s weight was

monitored on daily

basis to serve as

baseline data to monitor

 patient nutritional status

7. Offer assisted

mouth care.

7. Assisted mouth care

was given before and

after meals to stimulate

patient appetite

31/01/2022 Risk for Patient will 1. Give insulin 1. Insulin injections 07/02/22
Goal fully
infection be free from injection were given aseptically
met as
10:00am related to infection throughout aseptically. to reduce blood glucose 7:00 am
evidenced
hyperglycemia hospitalization level to normal and
by;
period as prevent infection

evidenced by:

1. The nurse observing that 1. The nurse

patient shows no signs of 2. Teach patient 2. Patient was taught observing

infection how to inspect how to inspect her skin that patient

2. Patient verbalizing that her skin for for wounds and sores to shows no

she does not feel feverish wounds, sores prevent infection signs of

which indicate no sign of and lacerations. infection

infection. 2. Patient

3. Teach her to 3. Patient was taught to verbalizing

put on protective put on protective that she

clothing before clothing before does not

exercise. exercise. feel feverish

4. Teach patient 4. Patient and family

and family signs were educated on the

and symptoms signs and symptoms of

of infection like infection.

fever.
5. Assess the

skin integrity

and observe the 5. Daily assessment of

skin for cuts, her skin for cuts,

blisters and blisters and break in the

break in the skin were done to rule

continuity of out any source of

skin. infection

6. Monitor vital

signs especially

temperature to 6. Vital signs especially

ascertain any temperature was

possible assessed daily to rule

infection. out infection

01/02/2022 Altered bowel Patient will be 1. Reassure 1. Patient was reassured that she 03/02/22 Goal fully

movement able to regain her patient. will regain her normal bowel 2:00pm met as

2:30pm (constipation) normal bowel movement. evidenced

related to lack movement by;

of exercise. within 48 hours 2. Assess for 2. Factors that aggravate

as evidenced by; factors that constipation such as lack of . 1. nurse

1. nurse aggravates exercise and inadequate fluid observing

observing that constipation. intake were assessed. that patient

patient has a has a

normal bowel 3. Encourage 3. Patient was encouraged to take normal

movement patient to take in in more fluids and fibre foods like bowel

2. patient more fluids and orange was given to prevent movement

verbalizing that fibre diet. constipation 2. patient

there is absence 4. Encourage 4. Patient was assisted in verbalizing

of the patient to performing range of motion that there is

constipation perform range of exercise to improve her bowel absence of

motion exercise. movement the

constipation

5. Administer

prescribed 5. Intravenous fluid (normal

intravenous saline) was administered to help

fluids. soften fecal contents and prevent

constipation

6. Administer 6. Prescribed laxative such as

prescribed magnesium hydroxide was

laxative and administered soften stools and

stool softeners. promote bowel elimination