NURSING CARE PLAN

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

STO: Independent: 1. Influence of choice

Subjective: After 4 hours of giving 1. Assessed patient’s of interventions
effective nursing ability to perform tasks/ assistance
“Di siya gaano makakilos interventions, the patient noting reports of 2. Enhance rest to After 4 hours of giving
at nanghihina” as will be able to cope with weakness, fatigue and lower body’s oxygen effective nursing
verbalized by the patient’s fatigue as evidenced by difficulty accomplishing requirements, and interventions, the patient
companion. verbalized feelings of task. reduces strain on was able to cope with
comfort and increase 2. Recommended quiet the heart and lungs fatigue as evidenced by
activity participation atmosphere; bed rest if 3. Enhances lung verbalization of feelings of
indicated stress-need to expansion to comfort and participating in
LTO: monitor and limit maximize passive ROM
Within 3 days of giving visitors, phone calls oxygenation for
Objective: nursing interventions, the and repeated cellular uptake.
• appeared weak patient will be able to unplanned interruptions 4. Although help may
• pale demonstrate an increase in 3. Elevated head of bed be necessary, self
• patient is lethargic activity tolerance as as tolerated. esteem is enhanced Within 3 days of giving
• dependent on others evidenced by doing simple 4. Provided/recommended when pt does things nursing intervention, the
care ADL’s assistance with for self. patient was not able to do
• always lying on bed activities / ambulation 5. promotes adequate simple ADLs
as necessary, allowing rest energy level,
pt to do as much as and alleviates strain
possible] on the cardiac and
5. Assisted pt to prioritize respiratory systems.
ADLs/desired activities.
 Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective: Elevated body Short Term Goal: Independent Nursing After 8 hours of
“Mainit ang katawan temperature related to Action: - Serves at baseline rendering effective
niya”as verbalized by the bacterial infection Within 8 hours of -Monitor vital sign data. nursing intervention the
patient. effective nursing -To know the fluid goal was completely met
intervention patient body - Monitor intake and balance of the body as evidenced by patient’s
temperature will be output body temperature
decrease from 38.6- - To reduce body decreases from 38.6-
Objective: 37.5˚C - Perform TSB temperature through the 37.5˚C.
process of conduction Patient’s skin not warm
BP – 110/70mmHg - To prevent dehydration to touch. Normal
Temp. – 38.6˚C Long Term Goal: and support circulating complexion of the skin.
RR – 30bpm -Increase oral fluid intake volume.
PR – 67bpm After period of - To provide conducive
hospitalization, the place to rest .Inform the
- Flushing of skin patient will be able to - Provide safe & quite patient about proper
- Skin warm to touch know the proper environment management of fever
management of - To be able for the
hyperthermia -Inform the patient about patient to know the
proper management of proper management.
fever

Dependent nursing -To elevate the patient’s

intervention: body temperature.
- Administer medications
as order by physicians
such as Paracetamol or
any anti –pyretic drugs.