B. NURSING CARE PLAN

1. NURSING CARE PLAN FOR ACUTE PAIN

CUES NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBEJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective:

The client

verbalized,” Ang

masakit lang sa

akin ngayon ay

yung tahi ko.”

Objective:

Patient’s

pain scale

score is 4

(Moderate

Pain)

Acute Pain

r/t surgical

incision

In the past, pain

control was a

major problem

after cesarean

birth. Pain was

so intense from

the uterine or

abdominal

incision that it

interfered with a

woman’s ability

to move and

deep breathe.

LONG TERM:

After the

nursing

intervention,

the client will

be able to

have a

reduced pain

in the pain

scale of 2.

SHORT

TERM:

INDEPENDENT:

1. Assess vital

signs.

2. Encourage

verbalization of

feelings about

the pain.

3. Provide

additional

comfort

measures; e.g.

back rub, heat/

1. Changes

in these vital

signs often

indicate

acute pain

and

discomfort.

3. Improves

circulation,

The client’s

pain has been

reduced to

pain scale of

2.

Facial

grimace

(Source:

Maternal and

Child Health

Nursing by

Adelle Pillitteri)

After the

nursing

intervention

the client will

be able to

apply nursing

intervention

intended to

improve

condtion.

cold

applications.

4. Encourage

use of relaxation

techniques; e.g.

deep breathing

exercises.

5. Encourage

adequate rest

periods.

DEPENDENT:

6. Administer

analgesics as

reduces

muscle

tension and

anxiety

associated

with pain.

Enhances

sense of well-

being.

4. Relieves

muscle and

emotional

tension

enhances

sense of

control and

may improve

coping

abilities.

indicated to

maximal dosage

as needed.

7. Provide

around the clock

analgesia with

intermittent

rescue doses.

5. To prevent

fatigue.

6. To

maintain

“acceptable”

level of pain.

7. Research

supports

need to

administer

analgesics

around the

clock initially

to prevent

rather than

merely threat

pain.

2. NURSING CARE PLAN FOR HYPERTHERMIA

CUES NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIO

N

OBJECTIVE

S

INTERVENTION

S

RATIONALE EVALUATIO

N

Subjective:

The client

verbalized,

“Mainit ang

pakiramdam ko.”

Objective:

Hyperthermi

a r/t Trauma

In a fever, the

set point of the

hypothalamic

thermostat

changes

suddenly from

the normal

level to a

higher value as

LONG

TERM:

After the

nursing

intervention

the client will

be able to

maintain core

INDEPENDENT:

1. Monitor the

client’s

temperature.

Note shaking

chills/profuse

diaphoresis.

1. The temperature

of 102°F-106°F

(38.9°C-41.1°C)

suggests acute

infectious disease

process. Fever

pattern may aid in

The client

was able to

maintain core

temperature

within normal

range after

the nursing

interventions.

Warm to

touch

Flushed

skin

Measurement:

T 38° C

a result of the

effects of

tissue

destruction,

pyrogenic

substances, or

dehydration on

the

hypothalamus.

(Source:

Fundamentals

of Nursing 7th

Edition, by

Kozier, page

488)

temperature

within normal

range.

SHORT

TERM:

After the

nursing

intervention

the client will

be able to

apply the

interventions

intended to

improve

condition.

diagnosis; eg.

sustained or

continuous fever

curves lasting

more than 24

hours suggest

pneumoccocal

pneumonia, scarlet

of typhoid fever;

remittent fever

(varying only a few

degress in either

direction) reflects

pulmonary

infections;

intermittent curves

or fever that

returns to normal

once in 24 hour

period suggests

septic episode,

2. Monitor

environmental

temperature,

limit/add bed

lines as

indicated.

3. Provide tepid

sponge baths,

avoid use of

alcohol.

septic endocarditis

or tuberculosis

(TB). Chills often

precede

temperature

spikes.

2. Room

temperature/numb

er of blankets

should be altered

to maintain near-

normal body

temperature.

3. May help reduce

fever.

DEPENDENT:

4. Administer

antipyretics.

4. Used to reduce

fever by its central

axon on the

hypothalamus;

fever should be

controlled in clients

who are

nuerotropenic or

asplenic.

However, fever

may be beneficial

in limiting growth of

organisms or

enhancing

autodestruction of

infected cells.

3. NURSING CARE PROCESS FOR DISTURBED BODY IMAGE

CUES NURSING

DIAGNOSI

S

SCIENTIFIC

EXPLANATIO

N

OBJECTIV

E

INTERVENTIO

N

RATIONALE EVALUATIO

N

Subjective:

As verbalized by the

client, “ feeling ko ang

taba-taba ko.”

Objective:

verbalization of

negative

feelings about

one’s self.

Disturbed

Body Image

r/t

Pregnancy

If we examine

our lives as

women, we can

see several

patterns of

emotional

crises. All the

periods---the

appearance of

menarche,

pregnancy, &

postpartum

recovery &

menopause---

are marked by

LONG

TERM:

After the

nursing

intervention,

the client

will be able

to recognize

&

incorporate

changes

into self-

concept

without

negating

INDEPENDENT

:

1. Discuss

meaning of

change to client.

2. Have client

describe self,

noting what is

positive & what

is negative.

1. A change in

function may

be more

difficult for

some to deal

with than a

change in

appearance.

2. To develop

new &

creative

solutions.

The client

was able to

recognize &

incorporate

changes into

self-concept

without

negating self-

esteem.

extraordinary

changes in

body image.

These

significant

changes in the

body are

almost always

accompanied

by

corresponding

emotional

changes.

(Source: “The

complete

postpartum

guide.”

p.43

By: Diane

Lynch-Fraser.)

self-esteem.

SHORT

TERM:

After the

nursing

intervention,

the client

will be able

to apply the

intervention

intended to

improve

condition.

3. Listen to

client without

comments &

responses to

the situation.

4. Visit client

frequently &

acknowledge

the individual as

someone who is

worthwhile.

5. Make time to

sit down &

talk/listen to

client while in

3. Different

situations are

upsetting to

different

people,

depending on

individual

coping skills &

past

experiences.

4. Provides

opportunities

for listening to

concerns &

questions.

the room.

6. Help client to

select & use

clothing &

make-up.

7. Refer to

therapist or

counselor as

needed.

5. To

decrease

sense of

isolation or

loneliness.

6. To

minimize body

changes &

enhance

appearance.

7. Helpful in

identifying

ways/ devices

to regain &

maintain

independence

. Client may

need further

assistance to

resolve

persistent

emotional

problems.

4. NURSING CARE PROCESS FOR IMPAIRED SKIN INTEGRITY

CUES NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

GOAL AND

OBJECTIVE

INTERVENTION RATIONALE EVALUATION

Subjective:

The client verbalized

“Sumasakit yong

tahi ko kapag

Impaired skin

integrity

related to

surgery

The skin serves

as the primary

line of defense

against

bacterial

invasion. When

LONG

TERM:

After the

nursing

intervention,

INDEPENDENT:

1. Assess skin

daily. Note

color, turgor,

circulation and

1.

Establishes

comparative

baseline

After the

nursing

intervention,

the client able

to improved

gumagalaw ako.”

Objective:

Presence of

surgical

incision

skin is incised

for a surgical

procedure, this

important line of

defense is lost

(Source:

Maternal and

Child Health

Nursing,

Pillitteri p.567)

Surgical

incisions heal

by primary

intention or by

the gradual

removal and

replacement of

dead or

damaged cells

the client will

be able to be

free

of/display

improvement

in wound

lesion

healing.

SHORT

TERM:

After the

nursing

intervention,

the client will

be able to

apply

The

Intervention

intended to

sensation.

Describe

measure lesions

and observe

changes.

2.

Maintain/instruct

in good skin

hygiene; e.g.,

wash

thoroughly, pat

dry carefully and

gently massage

with lotion or

appropriate

cream.

providing

opportunity

for timely

intervention.

2.

Maintaining

clean, dry

skin provides

a barrier to

infection.

Patting skin

dry instead of

rubbing

reduces skin

of dermal

trauma to

dry/fragile

skin.

Massaging

increases

wound lesion

healing.

at the wound

site with new

cells produced

by the

surrounding

tissue.

(Source:

Maternal and

Child Health

Nursing,

Pillitteri p. 582)

improve

condition.

3. Reposition

frequently.

4. Maintain

clean, dry,

wrinkle-free

linen, preferably

soft cotton

fabric.

circulation to

the skin and

promotes

comfort.

3. Reduces

stress on

pressure

points,

improves

blood flow to

tissues and

promotes

healing.

4. Skin

friction

caused by

movement

over

wet/wrinkled

5. Encourage

ambulation / out

of bed as

tolerated.

DEPENDENT:

6. Provide

foam / flotation /

alternate

pressure

mattress or bed.

or rough

sheets leads

to irritation of

fragile skin

and

increases risk

of infection.

5. Decreases

pressure on

skin from

prolonged

bedrest.

6. Reduces

pressure on

skin, tissue

and lesions.

7. Apply /

administer

topical /

systemic drugs

as indicated.

8. Refer to

physical therapy

for regular

exercise /

activity program.

7. Used in

treatment of

skin lesions.

Use of

agents such

as prederm

spray can

stimulate

circulation,

enhancing

healing

process.

8. Promotes

improved

muscle tone

and skin

health.

5. NURSING CARE PLAN FOR FEAR

CUES NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective:

Client verbalized:

“Takot ako

gumalaw kasi baka

bumuka ung tahi

ko”

Objective:

Patient has

avoidance to

move

Fear r/t

surgical

incision

Fear is an

emotion or

feeling of

apprehension

aroused by

impending or

seeming

danger, pain or

other perceived

threat. The fear

may be in

response to an

immediate or

LONG

TERM:

After nursing

intervention,

the client will

be able to

minimize her

fear.

SHORT

TERM:

INDEPENDENT:

1. Ask client’s

feeling about

her fear.

2. Encourage

contact with a

peer who has

successfully

dealt with a

similar situation.

1.

Expressing

client’s

feeling may

lessen her

fear and ease

her anxiety

2. Client is

more likely to

believe other

who have had

Client was

able to

minimize her

fear

Increased

respiratory

current threat,

or in response

to something

the person

believes will

happen

(Source:

Fundamentals

of Nursing

p1017)

After the

nursing

intervention

the client will

be able to

apply

intervention

intended to

improve

condition.

3. Discuss to

client proper

positioning,

transferring and

ambulation to

assure client

that her suture

will not open.

4. Assist client

in positioning,

transferring and

ambulation

similar

experience

3. Provides a

healthy outlet

for energy

generated by

feeling and

promotes

relaxation

6. NURSING CARE PLAN FOR RISK FOR INJURY

CUES NURSING

DIAGNOSI

S

SCIENTIFIC

EXPLANATIO

N

OBJECTIVE

S

INTERVENTION

S

RATIONALE EVALUATIO

N

NOTE:

Risk

diagnosis is

not

evidenced

by signs

and

symptoms,

as the

problem

has not

occurred

and nursing

intervention

s are

directed at

prevention.

Risk for

injury r/t

Post-

operative

condition

Risk for injury

is a state in

which the

individual is at

risk for injury

as a result of

environmental

conditions

interacting with

the individual’s

adaptive and

defense

resources.

(Source:

Fundamentals

of Nursing 7th

Edition, by

Kozier, page

673)

LONG

TERM:

After the

nursing

intervention

the client will

be able to

demonstrate

behaviors,

lifestyle

changes to

reduce risk

factors and

protect self

from injury.

SHORT

TERM:

INDEPENDENT

1. Assess mood,

coping abilities,

personal styles.

2. Ascertain

knowledge of

safety

needs/injury

prevention and

motivation.

3. Provide

information

regarding the

1. Some mood, coping

abilities and personal

styles might result in

carelessness/increase

d risk-taking without

consideration after the

consequences.

2. To prevent injury in

home, community and

work setting.

3. Providing, in a

simple and direct

manner, specific

factual information into

The client

was able to

demonstrate

behavior and

lifestyle

changes to

reduce risk

factors and

protect self

from injury.

After the

nursing

intervention

the client will

be able to

apply

interventions

intended to

improve

condition.

condition that

may result in

increased risk of

injury.

4. Discuss the

importance of

self-monitoring

condition/emotion

s that can

contribute to

occurrence of

injury.

DEPEDENT

5. Refer to the

resources as

indicated.

the client.

4. Discussion

encourages

participation by

learner.

5. A discharge note

and referral summary

are completed when

the client is being

discharged and

transferred to another

institution or to a home

setting where a visit by

a community health

nurse is required.

7. NURSING CARE PLAN FOR RISK FOR POSTOPERATIVE POSITIONING INJURY

CUES NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVE INTERVENTION RATIONALE EVALUATION

NOTE:

A risk

diagnosis is

not evident by

signs and

symptoms, as

d problem has

not occurred

and nursing

intervention

are directed at

prevention

Risk for

Postoperative

Positioning

Injury

Surgery can

involve many

body systems

both directly

and indirectly

and is a

complex

experience for

the client.

Maintain

respiratory and

skeletal muscle

function to

prevent post

LONG TERM:

After nursing

intervention,

the client will

be able to be

free from any

untoward

injury.

SHORT

TERM:

INDEPENDENT:

1. Discuss the

length of

procedure and

customary

positioning

2. Provide

safety measures

♪ lock/cart bed

♪ maintain

body alignment

♪ protect body

1. To increase

awareness of

potential of

potential

complications

2. To maintain

position and

prevents client

from any injury

Client was able

to be free from

any untoward

injury

surgical

complications.

(Source:

Medical-

Surgical

Nursing

handbook p585)

After the

nursing

intervention

the client will

be able to

apply

interventions

intended to

improve

condition.

from contact

with metal parts

of the operating

room

♪ position

extremities to

facilitate

periodic

evaluation of

safety,

circulation,

nerve pressure

and body

alignment

♪ reposition

slowly and at

transfer and in

bed

3. Assist client

in changing

3. To prevent

bed sores and

promote skin

and tissue

positions and

transferring

integrity.

8. NURSING CARE PLAN FOR IMPAIRED BED MOBILITY

CUES NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

GOAL AND

OBJECTIVE

INTERVENTION RATIONALE EVALUATION

Subjective:

The client

verbalized “Medyo

nahihirapan akong

gumalaw kase nga

dahil sa tahi ko.”

“Kailangan dahan-

dahan lang kase

kapag napamali ng

galaw kumikirot

yong parte na may

tahi.”

Impaired

bed mobility

related to

pain

discomfort

The sensory

experience of

pain depends

on the

interaction

between the

nervous system

and the

environment.

The processing

of noxious

stimuli and the

resulting

LONG

TERM:

After the

nursing

intervention,

the client will

be able to

demonstrate

techniques /

behaviors

that enable

safe

INDEPENDENT:

1. Assist on / off

bedpan and into

sitting position

when possible.

2.

Demonstrate /

assist with

transfer

techniques and

use of mobility

1. Facilitates

elimination.

2. Facilitates

self-care and

client’s

independence.

Proper

transfer

techniques

The client was

able to

demonstrate

techniques /

behaviors that

enable safe

repositioning.

Objective:

impaired

ability: turn

side to side

perception of

pain involve the

peripheral and

central nervous

system.

(Source:

Medical-

Surgical

Nursing,

Brunner and

Suddarth p.

220)

repositioning.

SHORT

TERM:

After the

nursing

intervention,

the client will

be able to

apply the

interventions

intended to

improve

condition.

aids.

3. Encourage

continuation of

exercises.

DEPENDENT:

4. Provide

foam / flotation

mattress.

prevent

shearing

abrasions

dermal injury

related to

scooting.

3. To

maintain /

enhance gains

in strength /

muscle

control.

4. Reduces

pressure on

skin / tissues

that can impair

circulation,

potentiating

risk of tissue

ischemial

breakdown.

9. NURSING CARE PLAN FOR SELF-CARE DEFICIT

CUES NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective:

The patient

stated, “Eto

nga hindi ako

makaligo kasi

masakit…”

Objective:

Self-care

deficit related

to Post-

Operative

Incision

A self-care

deficit exists

when the self-

care agency is

not able to

meet some or

all the

components of

Therapeutic

Self-Care

LONG

TERM:

After the

nursing

intervention,

the patient

will be able to

perform self-

care activities

within level of

INDEPENDENT:

1. Provide

privacy during

personal care

activities.

2. Inspect skin

1. Privacy

enables a client

to participate

without worrying

about later

embarrassment.

2. Presence of

such lesions may

The patient

has able to

perform self-

care activities

with in level of

own ability.

Able to

change

her

clothes

but

unable

to take

a bath.

Demand. own ability.

SHORT

TERM:

After the

nursing

intervention,

the client will

be able to

apply the

interventions

intended to

improve

condition.

regularly

3. Encourage

scheduling

activity early in

the day or during

the time when

energy level is

test.

4. Avoid doing

things for client

that client can do

for self,

providing

require treatment

as well as signal

the need for

closer monitoring

/ protective

intervention.

3. Clients with

MS expand a

great deal of

energy to

complete ADL’s,

increase the risk

of fatigue, with

often progresses

through the day.

4. These clients

may become

fearful and

dependent and

assistance as

necessary.

5. Encourage

client to perform

self-care to the

maximum of

ability as defined

by client. Do not

rush client.

although

assistance is

helpful in

preventing

frustration it is

important for

client to do as

much as possible

for self to

maintain self-

esteem and

promote

recovery.

5. Promotes

independence

and sense of

control, may

decrease

feelings of

helplessness.

10. NURSING CARE PLAN FOR DECISIONAL CONFLICT

CUES NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective:

The client

verbalized,

“Noong una,

hindi dito ang

plano kong

manganak.”

Objective:

The

client

has

delayed

Decisional

Conflict r/t

lack of

relevant

information.

Uncertainty

about course of

action to be

taken when

choice among

competing

actions involves

risk, loss or

challenged to

personal life

values.

(SourceNANDA)

LONG TERM:

After the

nursing

intervention,

the patient will

be able to

decide to

which

institution she

will give birth.

SHORT

TERM:

INDEPENDENT:

1. Encourage

verbalization of

conflict.

2. Determine

current

knowledge.

1. Lack of

information

can interfere

client’s

response to

illness

situation.

2. Provides

clues to assist

client to

develop

coping and

The patient

able to decide

to which

institution she

gave birth.

decision

-making. After the

nursing

intervention,

the client will

be able to

apply the

interventions

intended to

improve

condition.

3. Correct

misperceptions

client may have

and provide

information.

4. Encourage

involvement of

family as

desired.

DEPENDENT:

5. Refer to other

resource as

necessary.

regain

equilibrium.

3. Provides for

better

decision-

making.

4. Assist in

identification

and correction

of perception

of reality and

enables

problem

solving to

begin.

5. To provide

support for the

client.

Additional

assistance

may be

needed to

help client

resolve

making

decisions.

11. NURSING CARE PLAN FOR INEFFECTIVE BREASTFEEDING

CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION

Subjective:

The client

verbalized,

“Ayokong

magpabreastfeed.”

Objective:

Ineffective

Breastfeeding

r/t Knowledge

Deficit.

Dissatisfaction

or difficulty a

mother, infant

or child

experiences

with the

breastfeeding

process.

LONG TERM:

After the

nursing

intervention,

the client will

be able to

have effective

breastfeeding.

SHORT

TERM:

After the

nursing

intervention,

the client will

be able to

apply the

intervention

INDEPENDENT:

1. Assess client

knowledge

about

breastfeeding

and extent of

instruction that

has been given.

2. Encourage

discussion of

current

breastfeeding

experience.

3. Determine

maternal

1. Maybe for

some reasons

that the client

misinterpreted

the

instruction.

2. To assess

furthermore.

3. Maybe she

is in the stage

of “Taking- in

The client

assumes

responsibility

for effective

breastfeeding.

intended to

improve

condition.

feelings.

4. Give

emotional

support to

mother. Use 1:1

instruction with

each feeding

during hospital

stay/ client visit.

5. Promote early

management of

breastfeeding

problems.

6. Encourage

spouse

education and

Phase”.

4. Because

some mothers

wanted to

have an

attention due

to their

condition.

5. So that we

can assure

the main

problem of

the client.

support when

appropriate.

6. For

emotional

support to the

mother or the

client.

12. NURSING CARE PLAN FOR RISK FOR INFECTION

CUES

NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATIO

N

OBJECTIVES INTERVENTION RATIONALE EVALUATION

NOTE:

Risk diagnosis

is not

evidenced by

signs and

symptoms, as

the problem

has not

Risk for

infection

related to

surgical

incision

A wound can

be infected

with

microorganism

s at the time of

injury, during

surgery, or

postoperatively

LONG TERM:

After the

nursing

intervention,

the patient will

be able to

prevent or

reduce risk of

INDEPENDENT:

1. Observe for

localized signs of

infection at

insertion sites of

invasive lines,

sutures, surgical

incisions or

1. Provides

information

about the

severity and

presence of

infection.

The patient’s

risk for

infection has

been

prevented.

occurred and

nursing

interventions

are directed at

prevention.

. Surgical

infection is

most likely to

become

apparent 2 to

11 days

postoperatively

.

Contamination

of a wound

surface with

microorganism

s (colonization)

is an inevitable

result. Because

the colonizing

organisms

compete with

new cells for

oxygen and

infection.

SHORT TERM:

After the

nursing

intervention the

client will be

able to apply

interventions

intended to

improve

condition.

wounds.

2. Practice/

instruct in Good

Handwashing

and aseptic

wound care.

3. Monitor the

vital signs. Note:

onset of fever,

chills,

diaphoresis,

reports of

increase

abdominal pain.

4. Cleanse

incisions or

insertion sites

2. Reduces

risk of

spread of

pathogens

3. Provides

information

about the

developing

sepsis and

abscess.

4. Prevents

introduction

of pathogens

nutrition, and

because their

by-products

can interfere

with a healthy

surface

condition, the

presence of

contamination

can impair

wound healing

and lead to

infection.

(Source:

Fundamentals

of nursing,

page 861,

Kozier)

daily and prn with

povidoneiodine or

other appropriate

solution.

5. Instruct client

or SO(s) in

techniques to

protect the

integrity of skin,

care for lesions,

and prevention of

spread of

infection.

6. Instruct the

patient in wound

healing.

7. Promote quiet

and restful

into the body

5. Prevents

introduction

of pathogens

into the body

6. To assess

the healing

process

7. To regain

energy for

faster

recovery

environment

conducive for rest

and sleep.

8. Provide

nutritious food.

DEPENDENT:

9. Administer

medication

regimen

(antibiotic) and

note the client’s

response to

determine

effectiveness of

therapy or

presence of side

8. To regain

energy for

faster

recovery

effects.

13. NURSING CARE PLAN FOR FLUID VOLUME EXCESS

CUES NURSING

DIAGNOSI

S

SCIENTIFIC

EXPLANATIO

N

OBJECTIVE

S

INTERVENTIONS RATIONALE EVALUATIO

N

Subjective:

The client

verbalized,

“Minamanas

ako.”

Fluid

volume

excess r/t

Pregnancy

Fluid volume

excess occurs

when the body

retains both

water and

sodium in

similar

proportions to

LONG

TERM:

After the

nursing

intervention

the client will

be able to

INDEPENDENT:

1. Measure I & O

noting positive

balance (intake in

excess of output).

Weigh daily, and

note gain more

1. Reflects

circulating volume

status,

developing/resoluti

on of fluid shifts,

and response to

After the

nursing

intervention

the client

was able to

demonstrate

fluid volume

Objective:

Edema

Measurement:

normal ECF.

This is

commonly

referred to as

hypervolemia

(increased

blood volume).

FVE is always

secondary to

an increase in

the total

sodium

content. In

FVE, both

intravascular

and interstitial

spaces have

an increased

water and

sodium

content.

demonstrate

fluid volume

balance, with

balanced I &

O, stable

weight, VS

within the

client’s

normal range

and absence

of edema.

SHORT

TERM:

After the

nursing

intervention

the client will

be able to

apply the

than 0.5 kg/day.

2. Monitor BP. Note

external jugular and

abdominal vein

distention.

3. Assess the

respiratory status,

noting increased

therapy. Positive

fluid balance/weight

gain often reflects

continuing fluid

retention.

2. BP elevations

are usually

associated with

fluid volume excess

but may not occur

because of fluid

shifts of the

vascular space.

Distention of

external jugular

vein in associated

with vascular

congestion/edema.

3. Indicative of

balance.

Excess

interstitial fluid

is known as

edema.

(Source:

Fundamentals

of Nursing 7th

Edition, by

Kozier, page

1363)

interventions

intended to

improve

condition.

respiratory rate,

dyspnea.

4. Auscultate lung,

noting

diminished/absent

breath sounds and

developing

adventitious

sounds.

5. Monitor for

cardiac

dysrhythmias.

Auscultate heart

sounds, noting

development of

signs and

pulmonary

congestion/edema.

4. Increasing

pulmonary

congestion may

result in the

consolidation,

impaired gas

exchange, and

complications, e.g.

pulmonary edema.

5. May be caused

by heart failure,

decreased

coronary arterial

perfusion, or

electrolyte

symptoms (gallop

rhythm).

6. Assess degree

of

peripheral/depende

nt edema.

7. Measure

abdominal girth.

8. Provide frequent

imbalance.

6. Fluid shift into

tissues as a result

of sodium and

water retention,

decreased albumin,

and increased

antidiuretic

hormone (ADH).

7. Reflects

accumulation of

fluids (ascites)

resulting from loss

of plasma

proteins/fluid into

the peritoneal

mouth care;

occasional ice

chips, schedule

fluid intake round

the clock.

DEPENDENT:

9. Monitor serum

albumin and

electrolytes.

space.

8. Decreased

sensation of thirst

especially when

fluid intake is

restricted.

9. Decreased

serum albumin

affects the plasma

colloid osmotic

pressure resulting

in edema

formation. Reduced

renal blood flow

accompanied by

elevated ADH and

10. Monitor serial

chest x-rays.

11. Restrict sodium

and fluids as

indicated.

aldosterone levels

and the use of

diuretics may

cause various

electrolyte

shifts/imbalances.

10. Vascular

congestion,

pulmonary edema,

and pleural

effusions frequently

occur.

11. Sodium may be

restricted to

minimize fluid

retention

extravascular

sources. Fluid

restriction may be

—

12. Administer salt-

free

albumin/plasma

expanders as

indicated.

13. Administer

medications as

indicated:

necessary to

correct/prevent

dilutional

hyponatremia.

12. Albumin may

be used to increase

the colloid osmotic

pressure in the

vascular

compartment,

thereby increasing

effective circulating

volume and

decreasing

formation of

ascites.

13. Used with

caution to control

edema and ascites,

DIURECTICS

POTASSIUM

POSITIVE

INOTROPIC

DRUGS and

ARTERIAL

VASODILATORS

block effect of

aldosterone, and

increase water

secretion while

sparing potassium

when conservative

therapy with bed

rest and sodium

restriction does not

alleviate problem.

Diuretic given with

coordination with

albumin

administration may

enhance fluid

removal. Serum

and cellular

potassium are

usually depleted

because of liver

disease and urinary

losses. Given to

increase cardiac

output/improve

renal blood flow

and function,

thereby ±reducing

excess fluid.

14. NURSING CARE PLAN FOR FATIGUE

CUES NURSING

DIAGNOSIS

SCIENTIFIC

EXPLANATION

OBJECTIVE INTERVENTION RATIONALE EVALUATION

Subjective:

The client

verbalized, “Tulog

lang ako ng tulog

kasi pakiramdam

Fatigue

related to

stress

It is though that

a person who is

moderately

fatigued usually

has a restful

sleep. Fatigue

LONG

TERM:

After the

nursing

intervention,

the patient

INDEPENDENT:

1. Discuss

lifestyle changes

or limitations

imposed by

1. Discussion

encourages

participation by

learner and

permits

The patient

has improved

sense of

energy.

ko lagi akong

pagod na pagod…”

Objective:

Lethargic

and Drowsy

also affects a

person’s sleep

pattern. The

more tired the

person is the

shorter the first

period of

paradoxical

(REM) sleep.

As the person

rests, the REM

periods become

longer.

(Source:

Fundamentals

of Nursing,

page 1118, by

Kozier)

will be able

to improved

sense of

energy.

SHORT

TERM:

After the

nursing

intervention

the client will

be able to

apply the

interventions

intended to

improve

condition.

fatigue.

2. Encourage

client to do

whatever

possible. (e.g.

self-care, sit-up

in chair, walk).

Increase activity

level as

tolerated.

3. Instruct in

methods to

conserve

energy.

reinforcement.

And repetition at

learner’s level.

2. Enhances

strength/stamina

and enables

client to become

more active

without undue

fatigue.

3. To lessen

fatigue

4. Weakness

4. Assist with

self-care needs;

keep bed in low

position and

travel ways

clear of

furniture, assist

with ambulation

as indicated.

5. Provide

environment

conducive to

relief of fatigue.

Temperature

and level of

humidity are

known to affect

exhaustion.

may make

ADL’s different

to complete or

place the client

at risk for injury

during activity.

5. To lessen the

occurrence of

fatigue.

6. Prevent

dehydration

which increases

fatigue.

6. Encourage

adequate fluid

intake.