NURSING CARE PLAN

CUES NURSING RATIONALE OBJECTIVES NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS
Subjective Deficient Health literacy After 3-4 hours of 1. Establish rapport. To ensure After 3-4 hours of nursing
cues: knowledge is the ability to nursing interventions, a. Introduce self. compliance of the interventions, the goals and
regarding read, the family of the patient b. Explain purpose. patient. objectives have been met
“Di man kami condition, understand, and will be able to: and the family of the patient
maaram kun related to act on health 2. Select a variety of teaching Use of different were able to:
paano iton lack of information, strategies (e.g., pamphlets, visual means of accessing
niya nakuha exposure. including such 1. Participate in the aids, hand-outs) information 1. Participate attentively in
nga tasks as learning process. promotes learner the learning process.
sakit…”as comprehending Assessment retention.
verbalized by prescription 2. State at least 3 1. Assess readiness to learn and 2. State 3 factors that can
the patient’s labels, factors that can individual learning needs: cause PSGN.
grandmother. interpreting cause PSGN: a. Ascertain level of knowledge,
appointment a. Modifiable including anticipatory needs.
“Deri namon slips, 1. Diet b. Determine family’s ability or Individual may not
ini hiya iguin completing, 2. Sanitation readiness and barriers to be physically,
dadara ha health insurance b. Non-modifiable learning. emotionally, or
clinic o forms, and 1. Age mental capable at
hospital kay na following 2. Environment this time.
itatambal man instructions for 3. Economic
namon hiya, diagnostic tests. Status c. Be alert to signs of SO may need to
sugad han sip- Limited health avoidance. suffer
on ug ubo, literacy skills are 3. Verbalize in his/her consequences of 3. Verbalize the nursing
iguin often greater own understanding lack of knowledge process on his own
papatumar among certain the disease process. before he or she is understanding.
namon hiya groups: older ready to accept
hin adults, people 4. Verbalize in his/her information. 4. Verbalize in his own
Mucosolvan with limited own understanding understanding of
Tempra education, poor of therapeutic 2. Assess the SO’s motivation: Motivation may be therapeutic needs.
Paracetamol people, minority needs. a. Identify motivating factors for positive or
na iguin population, and the individuals. negative.
tutumar people with 5. Demonstrate, 5. Demonstrate, properly
nakaka-usa limited English properly check and b. Provide information relevant To prevent check and monitor the
kada adlaw proficiency. monitor the patient's only to the situation. overload. patient’s blood
hasta maupay Low health blood pressure. pressure.
an sakit.”As literacy skills are
verbalized by associated with 6. Enumerate at least 3 c. Provide positive reinforcement. Can enforce 6. Enumerate 3 ways on
the mother. poor health ways on how to continuation of how to prevent the
outcomes and prevent the efforts. recurrence of the
Objective higher health recurrence of the Health Teaching disease.
cues: costs. For disease. 1. Review disease process/ Provides
 History of example, a prognosis at family’s level of knowledge base
Past client may not a. Proper hygiene understanding. from which client
Illness: be able to read b. Proper hand a. Etiology cam make informed
a prescription. washing b. Risk Factors choice.
Hospitalization Clients with low c. Diet modification c. Disease Process
and Surgeries. literacy skills d. Proper
The patient have less environmental
has no history information sanitation 2. Instruct and demonstrate to It is vital that blood
of either minor about health the family the correct pressure be
or major promotion 7. Initiate necessary technique for monitoring controlled to 7. Initiate necessary
surgeries. No and/or lifestyle changes blood pressure. prevent further lifestyle changes and
other management of and participate in renal damage. participate in treatment
hospitalization a disease treatment regimen. regimen.
s done except process for 3. Explain prescribed medications Adequate
for current themselves and along with their rationale, understanding that
admission of their families dosage and expected or side effects are
PSGN. because they adverse side effects. common and often
are unable to subside with time
 Educational read the and can enhance
level of the educational cooperation with
father: materials. As a treatment plan.
College result, they have
undergradu higher rates of
ate hospitalization a. Co-amoxiclav 457 Antibiotic; Killing
 Educational than people with mg/5mL, BID bacteria that cause
adequate health
 level of the literacy. infections. It
mother: contains two
High school different medicines
graduate Reference: called amoxicillin
 Age of Fundamentals and clavulanic acid.
patient: 4 of Nursing by Amoxicillin belongs
years old, Kozier & Erb 8th to a group of
pre-primary Ed, page 496 medicines called
pupil "penicillins" that
can sometimes be
stopped from
working (made
inactive). The other
active component
(clavulanic acid)
stops this from
happening.
Adverse Effects:
Hypersensitivity,
dizziness,
headache

b. Furosemide , 20mg 1 ½ Loop diuretic;

tab, q6h Inhibits the
reabsorption of
sodium and
chloride from the
ascending limb of
the loop of Henle,
proximal and distal
renal tubule.
Increases renal
excretion of water,
sodium, chloride,
magnesium,
 potassium, and
calcium
Adverse Effects:
blurred vision,
dizziness
anorexia,
constipation,
diarrhea, dry
mouth,
excessive urination,
dehydration,
headache

c. Captopril, 25 mg/tab ½ ACE inhibitor; ACE

tab inhibitors block the
conversion of
angiotensin I to the
vasoconstrictor
angiotensin II. ACE
inhibitors also
prevent the
degradation of
bradykinin and
other vasodilatory
prostaglandins.
ACE inhibitors also
increase plasma
renin levels and
reduce aldosterone
levels. Net result is
systemic
vasodilation.
Adverse Effects:
Dizziness,
Drowsiness,
 Fatigue, Headache,
Insomnia
Cough, Dyspnea
Hypotension, Chest
Pain, Edema,
Tachycardia
Abdominal Pain,
Anorexia,
Constipation,
Diarrhea, Nausea,
Vomiting

d. Benzyl PCN, 800,00 IU Bactericidal; The

IVTT q6H penicillins and
penicillinase-
resistant antibiotics
produce
bactericidal effects
by interfering with
the ability of
susceptible bacteria
to build their cell
walls when they are
dividing.
These drugs
prevent the bacteria
from
biosynthesizing the
framework of the
cell wall, and
bacteria with
weakened cell walls
swell and then
burst from osmotic
pressure within the
 cell. Because
human cells do not
use the biochemical
process that
bacteria use to form
the cell wall, this
effect is a selective
toxicity.
Adverse Effects:
Hypersensitivity
reactions including
uticaria; fever; joint
pains; rashes;
convulsions;
diarrhea;
Anaphylaxis

e. Dopamine side drip @ 6 Vasopressors;

gtts/min stimulate
dopaminergic
receptors,
producing renal
vasodilation.
Adverse Effects:
Headache,
Dyspnea,
Arrhythmias,
Hypotension
Nausea, Vomiting,
Irritation at IV Site

4. Encourage proper hygiene. Edema interferes

 with cellular
nutrition, which
makes the client
more susceptible to
skin breakdown;
good hygiene is an
intervention to
prevent this
complication.

-Impetigo: Teach control of Impetigo is

contagion: thorough hand contagious.
washing, separate laundry for Infection is present
client’s linens, separate as long as skin
washing of client’s dishes, lesions are present.
hand-washing before and after Hand washing: To
contact with patient. reduce the risk of
cross-
contamination
among clients.

5. Discuss dietary plan.

- Low Protein, High Calorie This diet is
Diet designed to avoid
protein catabolism
and enables the
kidney to rest
because it handles
fewer protein
molecules and
metabolites.

- Low Salt Diet Sodium is

 restricted,
depending on the
amount of edema
noted.

- TFR: 495 mL/day Fluid intake is

usually restricted.

6. Emphasize the importance of a Nightingale

clean and healthy environment. believed that the
environment was
the major
component creating
illness in a patient;
she regarded
disease as “the
reaction of kindly
nature against the
conditions in which
we have placed
ourselves.”