NURSING CARE PLAN

NAME OF PATIENT: Lex WARD: Pedia Ward

DIAGNOSIS: Laryngotracheobronchitis, Greenstick fracture, Moderate Malnutrition DATE: June 3, 2020

ASSESSMENT BACKGROUND NURSING OBJECTIVES NURSING RATIONALE EVALUATION

KNOWLEDGE DIAGNOSIS INTERVENTION

Subjective: The most common Ineffective 1. Within the shift, Independent: 1. Client will maintain
Mother of form of croup is Airway client will - Place the child - Facilitates breathing and clear, open airways as
patient reports laryngotracheobro Clearance R/T maintain clear, elevated in a semi- maximal lung expansion evidenced by normal
extreme nchitis (LTB). It is Edema and open airways Fowler’s to high by lowering the breath sounds, normal
respiratory caused by an Constriction after interventions Fowler’s position; diaphragm. Frequent rate and depth of
distress acute viral of Airway and medications Reposition the child reposition prevents respiration, and ability
infection of the Secondary to frequently. pooling and stasis of to effectively cough up
Objective: larynx, trachea, Laryngotrache 2. Make the client secretions. secretions after
- O2 saturation and bronchi obronchitis feel relaxed and treatments and deep
of 93% resulting in the as comfortable as - Perform chest - Promotes expansion of breaths.
- Febrile obstruction below possible within 8h physiotherapy as the lungs, strengthen
- Stridor upon the level of the of duty indicated. respiratory muscles and 2. Client is able to
auscultation vocal cords. mobilization of verbalize feelings of
Spasmodic croup 3. Within the shift, secretions. comfort or relaxation /
is croup of sudden vital signs will fall Dependent: Client is able to sleep
onset, developing within the normal - O2 administration of - Provides adequate comfortably
at night and range of client’s 1-2L/min upon oxygenation required for
characterized by parameters after doctor’s order proper organ function. 3. Vital signs (O2
laryngeal interventions and Saturation, Temp, BP,
obstruction at the medications - Administer - Cefalexin decreases PR, and RR) are all
level of the vocal medications as risk of bacterial infection within the normal
cords caused by ordered by physician while Dexamethasone range of client’s
viral infections or and Budesonide act to parameters
allergens. Both Collaborative: clear patient’s airway
occur as a result of
upper respiratory
infection, edema, - Advise patient and - Adequate hydration can
and spasms that his family to increase help loosen mucus in the
cause respiratory his fluid intake oropharynx and prevent
problems such as dehydration.
respiratory
distress, decrease
O2 sat, and stridor
that the patient
manifests.

Source:
Martin, P. (2019,
April 10). 5 Croup
Nursing Care
Plans. Retrieved
from:
https://nurseslabs.
com/5-croup-
nursing-care-
plans/
 NURSING CARE PLAN
NAME OF PATIENT: Lora WARD: OB-GYNE
DIAGNOSIS: Inevitable Abortion DATE: June 3, 2020

ASSESSMENT BACKGROUND NURSING OBJECTIVES NURSING RATIONALE EVALUATION

KNOWLEDGE DIAGNOSIS INTERVENTION

Subjective: In inevitable Isotonic Fluid 1. Client will Independent: 1. Client verbalizes

- Patient reports abortion, there is Volume Loss verbalize - Monitor bleeding - Decrease in circulating accurate
increase in both bleeding R/T Bleeding understanding of and document vital blood volume can cause understanding of
abdominal and lower During causative factors signs especially BP hypotension and causative factors and
cramping abdominal Pregnancy and purpose of and HR. tachycardia. Alteration in purpose of therapeutic
cramping, Secondary to therapeutic HR is a compensatory interventions
Objective: accompanied by Inevitable interventions after mechanism to maintain
- Presence of some degree of Abortion conducting health cardiac output. Usually, 2. Client and family is
profuse vaginal cervical teaching the pulse is weak and able to state at least
bleeding dilatation. may be irregular if three statements about
- dilated cervix Bleeding may 2. Client and her electrolyte imbalance each: proper nutrition
range from family will also occurs. Hypotension and hydration and its
minimal to demonstrate is evident in hypovolemia. relevance, monitoring
severe and even behaviors to intake and output at
life threatening. monitor and - Assess skin turgor - Signs of dehydration are home, and also how to
With bleeding, correct deficit, as and oral mucous also detected through the identify danger signs
there is fluid appropriate after membranes for signs skin. of hypovolemia
loss. Deficient health teachings of dehydration.
fluid volume is a 3. Client will maintain
state or 3. Within the shift, - Monitor active fluid - Fluid loss from wound fluid volume at a
condition where client will loss from wound drainage, diarrhea, functional level as
the fluid output maintain fluid drainage, tubes, bleeding, and vomiting evidenced by stable
exceeds the fluid volume at a diarrhea, bleeding, cause decreased fluid vital signs, good skin
intake. It functional level as and vomiting; volume and can lead to turgor, good capillary
happens when well as stable maintain accurate dehydration. refill, moist mucous
water and vital signs membranes and
electrolytes are according to her input and output adequate urinary
lost as they exist normal record. output with normal
in normal body parameters. specific gravity.
fluids. This Dependent:
results in - Aminister IV therapy - IV therapy enables to
symptoms such as ordered replace fluid and
as dizziness, electrolyte loss
Muscle
weakness and - Administer - Ibuprofen is used as an
lethargy, and medications as per analgesic. Doxycycline is
decreased urine doctor’s order an antibiotic to prevent
output. infections, and Ferrous
sulfate is used to prevent
Sources: anemia in the patient.
Wayne, G. Collaborative:
(2019, March - Conduct a health - To ensure continuity of
20). Fluid teaching about proper care, increasing the
Volume Deficit. nutrition and patient and her family’s
Retrieved from: hydration and its knowledge level will
https://nurseslab relevance, and also assist in preventing and
s.com/deficient- instruct the family to managing the problem.
fluid-volume/ monitor intake and
output at home, and
also how to identify
danger signs of
hypovolemia
 NURSING CARE PLAN
NAME OF PATIENT: Leo WARD: -
DIAGNOSIS: Myocardial Ischemia R/O Myocardial Infarction DATE: June 3, 2020

ASSESSMENT BACKGROUND NURSING OBJECTIVES NURSING RATIONALE EVALUATION

KNOWLEDGE DIAGNOSIS INTERVENTION

Subjective: Myocardial Decreased 1. Patient Independent: 1. Patient

Angina pectoris, Ischemia occurs Cardiac demonstrates - Perform frequent - Shallow, rapid respirations demonstrates
dizziness when a coronary Output R/T several signs physical assessments are characteristics of adequate cardiac
vessel fails do Altered of adequate such as general decreased cardiac output. output as evidenced
Objective: deliver adequate Contractility cardiac output survey and monitor Decreased cerebral by blood pressure and
Cold diaphoresis, blood supply to Secondary to within 8h of vital signs perfusion and hypoxia are pulse rate and rhythm
BP of 80/60 the cardiac Myocardial shift. reflected in irritability, within normal
mmHg, PR of 50 muscles due to Ischemia restlessness, and difficulty parameters for patient;
beats/min and RR an occlusion or 2. Patient concentrating. Cold, strong peripheral
16 breaths/min, spasm. There is responds well clammy, and pale skin is pulses; and an ability
elevated CPK altered and remains secondary to compensatory to tolerate activity
MB:30 IU/L, WBC: contractility or a free of side increase in sympathetic without symptoms of
10,000 cells/mm steady decrease effects from nervous system stimulation dyspnea, syncope, or
and Troponin test in cardiac pump the and low cardiac output and chest pain.
of 0.15ug/ml function which medications oxygen desaturation.
can be used to 2. No side effects
eventually lethal. achieve - Check peripheral - Weak pulses are present occur within 1h after
With this, a adequate pulses and capillary in reduced stroke volume medication therapy
decrease in cardiac output refill and cardiac output. Capillary and desired outcomes
cardiac output after 1h of refill is sometimes slow or of normal vital signs
happens which medication absent. and increased cardiac
is the amount of administration. output are obtained
blood pumped - Note chest pain. - Low cardiac output can
by the heart per 3. Patient is Identify location, further decrease myocardial 3. Patient is able to
minute. The able to explain radiation, severity, perfusion, resulting in chest verbalize
required blood to actions and quality, duration, pain. understanding of the
meet the precautions to associated importance of lifestyle
metabolic take for manifestations such changes and
demands of the cardiac as nausea, and preventive measures
body is then disease, as precipitating and and states at least 5
inadequately well as lifestyle relieving factors. ways to do so,
pumped by the changes after especially committing
heart resulting in health - Closely monitor fluid - In patients with decreased to quit smoking.
the patient’s teachings. intake including IV cardiac output, poorly
symtoms such lines. Maintain fluid functioning ventricles may
as Angina restriction if ordered. not tolerate increased fluid
pectoris, volumes.
dizziness, and
cold diaphoresis. Dependent:
- Place on cardiac - Atrial fibrillation is common
monitor; monitor for in heart failure.
Sources: dysrhythmias,
Wayne, G. especially atrial
(2019, January fibrillation.
30). Decreased
Cardiac Output. - Administer - Depending on etiological
Retrieved from: medications as factors, common
https://nurseslab ordered medications include digitalis
s.com/decrease therapy, diuretics,
d-cardiac-output/ vasodilator therapy,
antidysrhy-thmics,
angiotensin-converting
enzyme inhibitors, and
inotropic agents.
Collaborative:
- Instruct patient and - Quitting smoking, healthy
family on lifestyle diet and exercise and
changes and additional therapy help
management of improve well-being of
Illness, especially patient and prevents the
preventive factors disease from developing
into Myocardial Infarction
 NURSING CARE PLAN
NAME OF PATIENT: Lina WARD: -
DIAGNOSIS: Type II Diabetes Mellitus DATE: June 3, 2020

ASSESSMENT BACKGROUND NURSING OBJECTIVES NURSING RATIONALE EVALUATION

KNOWLEDGE DIAGNOSIS INTERVENTION

Subjective: Diabetes Imbalanced 1. Client is aware Independent: 1. Client verbalizes

Fatigue, excessive Mellitus (Type 2) Nutrition: Less of appropriate - Encourage meal - To achieve health understanding of the
thirst and hunger is a chronic than Body food to eat and its planning. Discuss needs of the patient with importance of a
disease Requirements amounts of eating habits and the proper food diet for balanced diet and is
Objective: characterized by R/T Inability to calories/nutrients encourage diabetic his condition. If patient’s able to state at least 3
- Polyuria, insufficient Absorb after health diet (balanced diet) food preferences can be examples of a
Diaphoresis, FBS production of Nutrients teaching within as prescribed by the incorporated into the balanced meal
of 126 mg/dL, insulin in the Secondary to the shift. doctor. Identify food meal plan, cooperation
weight loss pancreas or Type 2 preferences, with dietary requirements 2. Client displays signs
when the body Diabetes 2. Display usual including ethnic and may be facilitated after of regained energy
cannot efficiently Mellitus energy level cultural needs. discharge. without reports of
use the insulin it without reports of fatigue after drug /
produces. fatigue after drug - Document actual - Weighing serves as an insulin therapy
Without insulin, / insulin therapy weight, do not assessment tool to
the body cannot estimate. Note total determine the adequacy 3. Patient is able to
absorb glucose 3. Establish daily intake including of nutritional intake. state a weight gain
and utilize it for weight gain goal patterns and time of goal and commits to
energy if patient desires eating. monitoring blood
production. This as well as glucose daily
process results commitment to - Observe for signs of - These potentially life-
in the monitoring blood hypoglycemia / threatening emergencies 4. Patient and her
inadequate glucose daily hyperglycemia: should be assessed and family is able to follow
intake of within shift changes in LOC, cold step by step procedure
nutrients and clammy skin, treated quickly per of measuring blood
insufficient to 4. Patient and her rapid pulse, hunger, protocol. glucose levels using a
meet metabolic family will know irritability, anxiety, glucometer via return
needs that result the proper headache, demonstration, as well
in symptoms method of lightheadedness, as insulin injection SQ
such as fatigue, measuring blood shakiness. via return
excessive thirst glucose using a demonstration
and hunger, and glucometer and Dependent:
weight loss. administration od - Perform - Beside analysis of
insulin therapy fingerstick glucose serum glucose is more
after testing. accurate than monitoring
Sources: demonstrations urine sugar. Urine
Wayne, G. glucose is not sensitive
(2017, enough to detect
September 24). fluctuations in serum
Imbalanced levels and can be
Nutrition: Less affected by patient’s
Than Body individual renal threshold
Requirements. or the presence of urinary
Retrieved from: retention.
https://nurseslab
s.com/imbalance - Administer regular - Regular insulin has a
d-nutrition-less- insulin as per rapid onset and thus
body- doctor’s order quickly helps move
requirements/ glucose into cells.
Collaborative:
- Instruct patient and - since patient is an
family danger signs of elderly, she cannot
diabetes mellitus, as perform self-care as
well as glucose efficiently. Participation of
monitoring and insulin family members
therapy encourage patient’s well-
being.