VIII.

NURSING CARE PLAN

ASESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
Activity Intolerance After 8 hours of nursing - Note presence of - Fatigue affects both Goal Met.
"Hindi masyado related to generalized intervention, the patient factors contributing to the client's actual and
nakakakilos anak ko body weakness as will be able to use fatigue (chronic illness). perceived ability to After 8 hours of nursing
kasi madali na siyang evidenced by fatigue. identified techniques to participate in activities. intervention, the patient
mapagod at nanghihina enhance activity was able to use
pa din siya" as tolerance - Adjust activities to - To prevent identified techniques to
verbalized by the patient's tolerance. overexertion. enhance activity
patient's father. tolerance
- Increase activity level - Greatly helps in
Objective: gradually. conserving energy,
increases tolerance in
Bedridden activity.

Fatigue - Plan care to carefully - To reduce fatigue.

balance rest periods
V/S taken as follows: with activities.

Temp: 36. 4 °C - Provide positive - Helps to minimize

RR: 31 cpm atmosphere. frustration and re-
HR: 113 bpm channel energy.

- Assist with activities - To protect client fromt

and provide assistive injury
devices.

- Provide medications - To promote well-being

and changes in
treatment regimen as
prescribed

- Provide comfort - Enhance ability to

analgesics for pain participate in activities
relief.
 ASESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:
Imbalance Nutrition less After 8 hours of nursing - Note age, body build, - Helps determine Goal Met.
"Kulang sa timbang ang than body requirements intervention, the patient strength, activity/rest nutritional needs.
anak ko sabi ng Doktor" related to inability to will be able to level. After 8 hours of nursing
as verbalized by the ingest adequate demonstrate behaviors intervention, the patient
patient's father. nutrients as evidenced to achieve appropriate - Encourage client to - To stimulate appetite. was able to
by lack of interest in weight. choose foods. demonstrate behaviors
Objective: food. to achieve appropriate
- Promote pleasant, - To enhance food weight.
Lack of interest in relaxing environment. intake.
eating nutritious foods
- Promote - To reduce possibility
Poor muscle tone adequate/timely fluid of early satiety.
intake.
Underweight
- Encourage small - To maximize nutrient
V/S taken as follows: frequent meals with intake without undue
food high in protein and fatigue.
Temp: 36. 4 °C carbohydrates.
RR: 31 cpm
HR: 113 bpm - Encourage and - To conserve energy
provide adequate rest needed for metabolic
periods. requirements

- Provide oral care - To reduce bad taste

before/after meals and left from medications,
at bedtime. prevents mouth sores.

- Administer vitamins as - Enhance patient's

prescribed. intake of food.
 ASESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective:
Risk for Infection related After 8 hours of nursing - Stress proper hand - Prevents transmission Goal Met.
Fatigue to inadequate secondary interventions, the client hygiene by all of infection
defenses (suppressed will identify caregivers between After 8 hours of nursing
Bedridden inflammatory response) interventions to therapies/clients. interventions, the client
prevent/reduce risk of - Limit exposures had identified
V/S taken as follows: infection - Limit visitors, uses of reduces cross interventions to
protective gears like contamination prevent/reduce risk of
Temp: 36. 4 °C mask should be infection.
RR: 31 cpm implemented
HR: 113 bpm - Prevents cross
- Maintain sterile contamination,
technique in all transmission of
procedures diseases

- Encourage - For mobilization of

ambulation, deep- secretions, and
breathing and coughing prevention of further
exercises, and respiratory infections.
positional changes

- Encourage adequate - Helps in strengthening

fluid and nutritional body's defenses.
foods intake

- Administer
prophylactic antibiotics - To promote well-being
and immunizations, as
indicated.