NURSING CARE PLAN

CUES NURSING OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION

SUBJECTIVE: Diarrhea related to SHORT TERM INDEPENDENT: SHORT TERM

“Madalas ako nadudume na
may kasamang dugo at
medyo basa. Nakaramdam
din ako ng pagsusuka kung
minsan at pananakit ng
tiyan” as verbalized by the
patient.
OBJECTIVE:
ACF of stool
 4-5X/ day
 brownish yellow
with blood streak,
loose and mucoid
 Hyperactive bowel
sounds
 Abdominal cramps
invasion of the lining of GOAL GOAL
the colon secondary to - Observe and record -To note for
infectious processes as After 30-45 minutes amount, characteristics degree of fluid After
manifested by patient’s of nursing and frequency of losses implementation of
verbalization, brownish intervention the bowel movement. appropriate nursing
yellow with blood client will be able to intervention, the
streak, loose and promptly replace - Increase oral fluid client was able to
musoid stools. fluids and intake -To replace fluid promptly replaced
electrolyte losses losses due to fluids and
through hydration frequent vowel electrolyte losses
and electrolyte movement through hydration
supplement as and electrolyte
evident by - Monitor intake and - To assess for supplement as
increasing oral fluid output decrease in fluid evidenced by
intake and volume resulting increased in oral
electrolyte balances to dehydration intake and
maintained
LONG TERM electrolyte balance
GOAL -To determine
- Assess for signs of client’s hydration - Goal fully met
After 3-4 hours dehydration status and
nursing intervention determine
the client will be dehydration
able to reestablish
hydration status as LONG TERM
to prevent GOAL
dehydration through DEPENDENT: -To replenish and
physical assessment establish After
and careful -Administer IV fluids hydration and implementation of
monitoring of intake as indicated with maintain appropriate nursing
and output. electrolyte electrolyte intervention, the
supplements (KCl) balance client was able
partially
reestablished
 -Inhibits nucleic hydration status as
acid of the to prevent
-Administer bacteria there by dehydration through
antiprotozoal eliminating spread absence of signs of
medication (Flagyl) of infection dehydration
minimum intake
and output

- Goal is partially
met
 CUES NURSING DIAGNOSIS OBJECTIVES NURSING RATIONALE EVALUATION
INTERVENTION
Fluid Volume Deficit
SUBJECTIVE: related to active fluid SHORT TERM INDEPENDENT SHORT TERM
volume loss ( diarrhea) GOAL > Encourage client to > To replenish GOAL
“Nararamdaman ko din na secondary to infectious increase oral fluid patient with fluid
nanghihina ako at para bang process as manifested by After 1-2 hours of intake volume losses After 1-2 hours of
palage akong walang lakas.” decrease in urine output, nursing implementing
decrease oral fluid intake intervention, the appropriate nursing
OBJECTIVES: ( 400-500 ml), poor skin client will intervention, the
Decrease in urine output turgor, pale nail beds, pale maintain adequate > To moisten the client maintained
25 cc/hr palpebral conjunctiva, fluid volume > Provide meticulous mucous adequate fluid
Decrease oral fluid slightly pale nasal and versus active fluid oral care (toothbrush membrane and volume versus
intake buccal mucosa cry and volume loss and mouthwash) prevent injury active fluid volume
( 400-500 ml) cracked lips, thready/weak through fluid from dryness loss as evidenced by
Poor skin turgor pulse hydration and an increase in oral
Pale nail beds monitoring of fluid intake from
Pale palpebral intake and output > Check voiding and > To check for 500 ml to at least
conjunctiva as evidence by record amount an increase or 1000ml with
Slightly pale nasal and moist mucous decrease fluid moistened mucous
buccal mucosa membranes, good losses membrane, good
Dry and cracked lips skin turgor, and skin turgor and
Thready/weak pulse increase in oral > Promote a quiet > To decrease increased urine
fluid intake from environment and bed oxygen demand output of 30cc/hr
500 ml to at least rest thereby
1000ml and resulting from - Goal partially
increased urine weakness met
output from 25
cc/hr to atleast 40
cc/hr > To assess for LONG TERM
> Regularly assess signs of GOAL
client for changes in dehydration and
LONG TERM conditions (e.g. mental monitor progress After 8 hours of
GOAL status, fatigability, of client. implementing
restlessness etc.) appropriate nursing
After 8hours of intervention, the
nursing >To measures if client reported a
intervention, the > Strictly monitor I/O client had slight increase in
client will have an enough fluid energy level and
increase in intake and output absence of
energy levels and complications as
prevent further verbalized by the
complication as client, “ Medyo ok
evident by DEPENDENT > For na ang pakiramdam
client’s > Administer IV fluids replacement of ko, hindi na ako
verbalization of as indicated fluids and gaano nanghihina.”
an increase in electrolytes
energy levels. - Goal partially
> To assess for met.
> Monitor client’s hydration status
urine specific gravity of the client
 DIAGNOSIS INDEPENDENT:
SUBJECTIVE: Acute pain related to SHORT TERM SHORT TERM
inflammatory response GOAL >Encourage adequate rest >To promote GOAL
“Pabalik balik yung sakit secondary to periods relaxation as to
ng tiyan ko. Humihilab compression of nerve After 15-30 prevent fatigue After 15-30
at para bang umiikot endings as manifested by minutes of nursing minutes of
yung sikmura ko”as patient’s verbalization intervention the implementing
verbalized by the patient and recurrent patient will be able >Provide comfort measures > To decrease appropriate nursing
abdominal pain, report a decrease in (e.g. back rub, proper pain through intervention the
guarding behavior pain perception positioning etc.) stimulation of patient reported a
OBJECTIVES: during episodes of through providing release of decrease in pain
pain, slight facial methods to endorphins scale from 7-8 to 6
Recurrent grimace, pain scale alleviate pains as out of 10
abdominal pain of 7-8 out of 10, evident by a
irritable and less decrease in pain Goal fully met
Guarding behavior pleasant, scale from 7-8 to at > Encourage deep > To assist in
during episodes of pain normal to least 6 breathing exercise muscle and LONG TERM
hyperactive bowel generalized GOAL
Slight facial grimace sounds. relaxation
Pain scale of 7-8 out of LONG TERM After 1-2 hours of
10 GOAL > Provide diversional >To lessen implementing
activities such as listening preoccupation to appropriate nursing
Irritable and less After 1-2 hours of to music and watching pain and lessen it intervention the
pleasant nursing television patient
Narrowed focus ( less intervention the >To reduce demonstrated
interested with patient will be able >Provide quiet and calm stimulation that behavioral
conversing to others) demonstrate environment and cluster may trigger pain modifications that
Normal to hyperactive appropriate nursing care perception has lessened pain
bowel sounds behavioral perception through
modifications to relaxation skills
lessen pain > To release and other comfort
perceived through > Encourage right sided endorphins and measures as
relaxation skills brain stimulation such as enhance well evidenced by
and comfort love, laughter and music being decrease irritability
measures as and decrease
evident by decrease Dependent: > To decrease preoccupation to
irritability and inflammation that pain
preoccupation to >Administer anti may cause pain
pain . inflammatory drugs
( Prednisone) -Goal fully met