COLLEGE OF NURSING

Silliman University
Dumaguete City

NURSING CARE PLAN

NURSING
CUES/EVIDENCES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective Data: Acute pain related At the end of my 8-hour Independent:
to leukocyte duty, patient will tolerate
 “Sakit kuno infiltration of pain as evidenced by: 1. Assess reports of pain. 1. Helpful in assessing
Note changes in need for
kaayo ang iyang systemic tissues
degree (use scale of 0– intervention; may
tiyan.” As  Describes 10) and site. indicate developing
verbalized by the satisfactory pain complications.
mother of the control at a level
patient. less than 8 on a 2. Monitor vital signs, 2. May be useful in
 Rated pain as 8 rating scale of 0 to note nonverbal cues, evaluating verbal
10 (10 being the e.g. muscle tension, comments and
out of 10 using
restlessness. effectiveness of
pain scale (10 highest and 0 as no
interventions.
being the highest pain at all).
and 0 as no pain 3. Provide quiet 3. Promotes rest and
at all)  Displays improved environment and enhances coping
well-being and reduce stressful abilities.
Objective Data: reduction in pain stimuli, e.g. noise,
lighting, constant
 Stiffness in joints behaviors like
interruptions.
 CBC Results: absence of facial
(07/02 at 5:46 grimacing. 4. Place in position of 4. May decrease
am) comfort and support associated bone/joint
WBC = 867,580 joints, extremities with discomfort.
cells/uL pillows/padding.
 Seg = 2% 5. Reposition 5. Improves tissue
PLT = 63 T periodically and circulation and joint
cells/uL provide/assist with mobility.
Blasts = 89% gentle ROM exercises.
Blood Uric Acid
= 7.20 mg/dL 6. Provide comfort 6. Minimizes need
 Facial grimacing measures (e.g. for/enhances effects
noted massage, cool packs) of medication.
 Restless and and psychological
irritable support (e.g.
 Grip not as encouragement,
strong as presence).
yesterday
 Would tire easily 7. Assist with/provide 7. Helps with pain
 Reduced diversional activities, management by
interaction with relaxation techniques. redirecting attention.
people and
environment 8. Rapid turnover and
8. Monitor uric acid level destruction of
as appropriate. leukemic cells
during
chemotherapy can
elevate uric acid,
causing swollen
painful joints in
some patients. 

Note: Massive
infiltration of WBCs
into joints can also
result in intense
pain.
 Dependent: Dependent:

1. Administer 1. Help prevent

medications as complications and
ordered. be relieved of pain.

NURSING
CUES/EVIDENCES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective Data: Activity intolerance At the end of my 8-hour Independent:
related to duty, patient will slowly be
 “Sige rani siyang generalized able to do ADLs and start 1. Evaluate reports of 1. Effects of leukemia,
fatigue, noting anemia, and
luya sukad nga gi weakness and participating in self-care
inability to participate chemotherapy may
admit siya.” As reduced energy activities as evidenced by: in activities or ADLs. be cumulative
verbalized by the stores (especially during
mother of the  Identifies negative acute and active
patient. factors affecting treatment phase),
activity tolerance necessitating
and eliminate or assistance.
Objective Data:
reduce their effects
 (+) Body malaise when possible. 2. Provide quiet 2. Restores energy
 Skin pallor on environment and needed for activity
entire body  Uses identified uninterrupted rest and cellular
 Low energy, techniques to periods. Encourage regeneration/tissue
drifts in and out enhance activity rest periods before healing.
of sleep tolerance. meals.
 Visibly more
exhausted  Participates 3. Implement energy- 3. Maximizes available
 Needs assistance willingly in saving techniques, energy for self-care
when going to necessary/desired e.g., sitting, rather tasks.
the bathroom activities. than standing,
 Loss of appetite etc. Assist with
  Restless and ambulation/other
irritable activities as
 Grip not as indicated.
strong as
yesterday 4. Schedule meals 4. May enhance intake
 Would tire easily around by reducing nausea.
 Reduced chemotherapy. Give
interaction with oral hygiene before
people and meals.
environment
 Does not want to 5. Recommend small, 5. Smaller meals
respond to nutritious, high- require less energy
questions protein meals and for digestion than
snacks throughout the larger meals.
day. Increased intake
provides fuel for
energy.

Dependent: Dependent:

1. Administer 1. Maximizes oxygen

supplemental oxygen available for cellular
as ordered. uptake, improving
tolerance of activity.

NURSING
CUES/EVIDENCES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective Data: Risk for Imbalanced At the end of my 8-hour Independent:
Nutrition: Less than duty, patient will show
 “Wala siya’y body requirements improvement in her 1. Note real, exact 1. These
r/t loss of appetite weight; do not anthropomorphic
gana mukaon nutrition as evidenced by:
and weakness estimate. assessments are vital
 sige, wala gani that they need to be
siya’y gana  Increased fluid and accurate. These will
mukaon ug food intake. be used as basis for
caloric and nutrient
pamahaw.” As
 Gain back interest in requirements.
verbalized by the
food.
mother of the 2. Take a nutritional 2. Family members
patient. history with the may provide more
 Displays
 Mother reported normalization of participation of accurate details on
that child laboratory values significant others. the patient’s eating
couldn’t finish that indicate signs of habits.
the same amount malnutrition.
3. Review laboratory 3. Laboratory tests play
of food she used values that indicate a significant part in
to finish. well-being or determining the
deterioration. patient’s nutritional
Objective Data: status. An abnormal
value in a single
diagnostic study
 Loss of appetite
may have many
 Vomitus = 120 possible causes.
mL
 Serum  This
 Serum albumin = albumin determines
2.80 g/dL degree of
 RBC = 2.6 protein
cells/uL reduction
 Potassium = 5.20 (2.5 g/dl
mEq/L signifies
 Movement and severe
reflexes are diminution;
slightly sluggish 3.8 to 4.5
due to g/dl is
exhaustion and normal).
body malaise
 Low energy,  RBC count  These counts
drifts in and out are
of sleep frequently
 Visibly more dropped in
exhausted malnutrition
 Skin pallor on revealing
entire body anemia.
 Appears  Potassium  Potassium is
confused typically
 Restless and elevated in
irritable malnutrition.
 Grip not as
strong as 4. Look for physical 4. The patient
yesterday signs of poor encountering
 Would tire easily nutritional intake. nutritional
deficiencies may
resemble to be
sluggish and
fatigued. Other
manifestations
include decreased
attention span,
confused, pale and
dry skin,
subcutaneous tissue
loss, dull and brittle
hair, and red,
swollen tongue and
mucous membranes.

5. Provide a pleasant 5. A pleasing

environment. atmosphere helps in
decreasing stress and
 is more favorable to
eating.

6. If patient lacks 6. Nursing assistance

strength, schedule
rest periods before
meals and open
packages and cut up
food for patient.
with activities of
daily living (ADLs)
will conserve the
patient’s energy for
activities the patient
values.

7. Consider six small 7. Eating small,

nutrient-dense meals frequent meals
instead of three larger lessens the feeling of
meals daily to lessen fullness and
the feeling of decreases the
fullness. stimulus to vomit.

Collaborative: Collaborative:

1. Refer to a dietitian 1. Experts like a

for complete nutrition
assessment and
methods for
nutritional support.
dietician can
determine nitrogen
balance as a measure
of the nutritional
status of the patient.
A negative nitrogen
balance may mean
protein malnutrition.
The dietician can
also determine the
patient’s daily
requirements of
specific nutrients to
promote sufficient
nutritional intake.
 SILLIMAN UNIVERSITY MEDICAL CENTER
FLUID INTAKE AND OUTPUT RECORD SHEET

Name: NJC__________________ Bed No. 434/PICU______ Date: July 3, 2019______

FLUID INTAKE 7 am to 3 pm 3 pm to 11 pm 11 pm to 7 am
Kind Vol. Kind Vol. Kind Vol.
H2O 480 cc

Oral Fluid

D5 .3% NaCl 1240 cc

Intravenous Fluid

TOTAL 1720 cc
FLUID LOSS
Urine (D) 3x 750 cc
Perspiration 333 cc
Visible Perspiration
Vomitus
Approx.
Stool 1x
177 cc
Suction
Misc.
TOTAL 1260 cc
Signature of Nurse Over
Printed Name K.J. Pileo, SN

Summary in 24 Hours
Total Fluid Intake _______________________ _______________________________
Total Fluid Loss _______________________ Signature of Nurse Over Printed Name
 Silliman University Medical Center
Dumaguete City

NURSES NOTES

Patient’s name: NJC______ Doctor: Dr. Genda Naguit Nuico_ Bed No: 434/PICU Form No. 2019-01

DATE TIME FOCUS D= Data A= Action R= Response

07/03 0800H Loss of appetite D: Seen lying on bed, awake and responsive
: Refused to eat breakfast
: Mother reported that child couldn’t finish the same amount of food
she used to finish
: Vomitus = 120 ml
: Low energy, drifts in and out of sleep
: Would tire easily
A: V/S taken and recorded
0845H : Administered medications as ordered
: Provided a pleasing environment that is favorable for eating
: Scheduled rest periods before meals
: Encouraged to eat small, frequent meals
: Referred to dietitian for complete nutrition assessment and
methods for nutritional support
R: Gained back little interest in food
: Appeared more energetic and rested
1000H Acute pain D: Seen still lying on bed, awake and responsive
: Complained of dull pain in the epigastric region of the abdomen
: Rated pain as 8 out of 10 (10 being the highest and 0 as no pain)
: Stiffness in joints
: WBC = 16,910 cells/uL
: Segmenters = 2%
: PLT = 63 T cells/uL
: Blasts = 89%
: Blood uric acid = 7.20 mg/dL
: Facial grimacing noted
: Restless and irritable
A: V/S taken and recorded
1015H : Provided quiet environment and reduced stressful stimuli
: Positioned comfortably and supported joints and extremities with
pillows
: Provided comfort measures such as cool packs
: Provided psychological support
: Provided diversional activities and relaxation techniques
1115H R: Felt a little better and comfortable
: Verbalized that pain was at a manageable level
 Silliman University Medical Center
Dumaguete City

NURSES NOTES

Patient’s name: NJC______ Doctor: Dr. Genda Naguit Nuico_ Bed No: 434/PICU Form No. 2019-01

DATE TIME FOCUS D= Data A= Action R= Response

07/03 1115H Acute pain R: Rated pain as 6 out of 10 (10 being the highest and 0 as no pain)
: Absence of facial grimacing
: Appeared a little active and rested
1200H Altered Comfort D: Seen still lying on bed, awake and responsive
: Skin pallor on entire body
: Movement and reflexes are slightly sluggish due to exhaustion and
body malaise
: Visibly more exhausted
: Restless and irritable
: Would tire easily
: Would keep tossing and turning on the bed
A: V/S taken and recorded
: Administered medications as ordered
1230H : Provided adequate rest periods
: Provided a calm and quiet environment with proper ventilation
R: Felt a little better and more comfortable
: Appeared more energetic and rested
: Endorsed to NOD ——————————————
 SILLIMAN UNIVERSITY MEDICAL CENTER
MEDICATION AND TREATMENT RECORD

Name: NJC________________________________ Bed No. 434/PICU_____________________

 SPECIMEN SIGNATURES OF NURSES ON DUTY
Printed Name Specimen Printed Name Specimen Signature Printed Name Specimen
Signature Signature
Kristine Jamille
R. Pileo, SN,
SUCN

Date Date Date Date Date

MEDICINE/ TREATMENT 07/03
Allopurinol 100 mg tab PO 8am
TID 12nn
8pm

Ceftriaxone Na 8am
(KEPTRIX) 1.5 g IV 8pm
infusion for 30 mins q12h

Lansoprazole 6 am
(PREVACID) 30 mg IVTT
OD

NaCl (Muconase) 0.65% 2am

30 ml nasal spray QID 8am
2pm
8pm
Paracetamol (BIOGESIC)
500 mg tab PO q4h PRN
for temp of 38°C

Prednisone (PRED) 20 8am

mg tab PO TID 12nn
8pm

Vincristine 2 mg slow IV
push

Hydrocortisone Na 12noc
Succinate 6am
(SOLUCORTEF) 85 mg 12nn
slow IVTT q6h 6pm