NURSING CARE PLANS

Assessment Diagnosis Planning Intervention Evaluation

Subjective Data: Independent: Short term Goal

“ Nahihirapan ako Ineffective tissue After 2 days of  Established rapport outcome:
makahinga” as verbalized perfusion related to nursing intervention,  Monitored Vital signs
blood loss as the client will increase  Monitor intake and output Goals are partially
by the patient.
manifested by low tissue perfusion and  Advised the patient to have a met. After 2 days of
Objective Data: hemoglobin count will have a normal quiet atmosphere and nursing
- weakness and hemoglobin count environment intervention, the
restlessness noted  Compared skin temperature and client increased
-capillary refill more than color with other limb when tissue perfusion but
3 seconds assessing extremity circulation not reach the
-Hemoglobin of 52 mg/dl  Assess motor and sensory normal hemoglobin
function count.
(Low)
 Advised to eat iron rich food -hgb of 74mg/dL
-V/S are as follows:  Instruct to do deep breathing - capillary refill less
Temp- 36.3 degree celcius exercise than 3 seconds
HR- 85 bpm  Encourage to have exercise at
RR: 25 cpm least 15 minutes
BP: 100/70  Massage the client as needed to
improve circulation
Dependent:
-Administered iron supplement as
ordered
-provide nebulization PRN as ordered

Assessment Diagnosis Planning Intervention Evaluation

Subjective Data: Chronic Pain related to Short term Goal: Independent: Short term Goal
“Ang tagal tagal na. Palagi pressure in the left inguinal  Provide cutaneous outcome:
nalang masakit tong puson
ko” as verbalized by the
patient.
Pain Scale: 8/10
Objective Data:
-Guarding the affected side
-Facial grimace noted
-Restlessness noted
-V/S are as follows:
Temp- 36.3 degree celcius
HR- 85 bpm
RR: 25 cpm
BP: 100/70
Assessment
region secondary to After 4 hours of nursing
cervical cancer intervention, the client
will be able to verbalize
reduction of pain.
Diagnosis Planning
stimulation (hot and
cold ) Goals are met. After 4
 Provide non hours of nursing
pharmacologic comfort intervention, the client
measures and verbalized reduction of
diversional activities pain
 Evaluate pain relief/
control at regular
intervals.
 Assessed for refereed
pain as appropriate
 Noted and investigated
changes from previous
reports
 Provide comfort
measures and quiet
environment
 Instruct and encourage
to use relaxation
technique such as focus
breathing
Dependent:
Administer analgesic as
ordered.
Intervention Evaluation

Subjective Data: Independent: Short term Goal

“Ang dami pa saking
lumalabas na dugo,
nanunyo na rin ang bibig
ko” as verbalized by the
patient.
Objective Data:
-pallor noted
Fluid volume deficit After 2 days of giving
related to cervical bleeding appropriate nursing
as manifested by low intervention, the client
hematocrit level will be able to maintain
fluid volume at a
functional level as
evidenced by moist
mucous membrane
 Established rapport
 Monitor V/S
 Encouraged to
increased fluid intake
 Recommend to avoid
caffeine
 Evaluate the CFAC
(color, frequency,
amount and
outcome:
Goals are met. After 2
days of nursing
intervention, the client
maintained fluid
volume at a functional
level as evidenced by
moist mucous
- (+)dizziness consistency) of urine membrane
-dry skin mucous  Regulate IVF
membrane noted Dependent:
 Infused PRBC with
-hematocrit of 22.5%
IVF as ordered.
-V/S are as follows:
Temp- 36.3 degree celcius
HR- 85 bpm
RR: 25 cpm
BP: 100/70

Assessment Diagnosis Planning Intervention Evaluation

Subjective Data: Independent: Short term Goal

“Ang dami pa saking Fluid volume deficit After 2 days of giving  Established rapport outcome:
lumalabas na dugo, related to cervical bleeding appropriate nursing  Monitor V/S
as manifested by low intervention, the client  Encouraged to Goals are met. After 2
nanunyo na rin ang bibig
hematocrit level will be able to maintain increased fluid intake days of nursing
ko” as verbalized by the fluid volume at a  Recommend to avoid intervention, the client
patient. functional level as caffeine maintained fluid
evidenced by moist  Evaluate the CFAC volume at a functional
Objective Data: mucous membrane (color, frequency, level as evidenced by
-pallor noted amount and moist mucous
- (+)dizziness consistency) of urine membrane
 Regulate IVF
-dry skin mucous
Dependent:
membrane noted  Infused PRBC with
-hematocrit of 22.5% IVF as ordered.
-V/S are as follows:
Temp- 36.3 degree celcius
HR- 85 bpm
RR: 25 cpm
BP: 100/70

Assessment Diagnosis Planning Intervention Evaluation

Subjective Data: Activity Intolerance
“Wala akong magawa ta
pirmi akong nahihilo mi
nangluluya man ako” as
verbalized by the patient
Objective data:
-prolonged bed rest
noted
-easy fatigability
-weak in appearance
-Vital signs are as
follows:
Temp- 36.3 degree celcius
HR- 85 bpm
RR: 25 cpm
BP: 100/70
Assessment
SHORT TERM INDEPENDENT:
related body GOAL:  Provide positive SHORT TERM
weakness After 8 hours of atmosphere while GOAL Evaluation:
nursing intervention, acknowledging difficulty Goals are met.
the client will be of the situation for the After 8 hours of nursing
able to verbalized client intervention, the client
activities suitable for  Plan for progressive verbalized activities
her condition and for increased of activity suitable for her
her to be level/ participation in condition and for her to
comfortable exercise as tolerated by be comfortable
the client such as
performing ROM
exercise daily
 Plan care to fully balance
periods with activities
 Discuss ways/activities
that could enhance
activity tolerance such as
walking and turning to
side
 Monitor Vital signs
 Provide enough
ventilation
 Assist patient with
activity
Diagnosis Planning Intervention Evaluation
Subjective Data:
“Di ko na alam gagawin related to depression
ko sa sakit na to” as
verbalized by the client. stressors associated
Objective Data:
- Depressed mood/
with mood
swings.
- Excessive crying
- Irritable
Ineffective coping SHORT TERM INDEPENDENT:
GOAL:  Establish rapport. SHORT TERM
in response to After 8 hours of GOAL Evaluation:
nursing  Apply therapeutic Goals are met.
with disease interventions, the communication. After 8 hours of nursing
condition patient will verbalize interventions, the
feelings with the  Active listen and identify patient verbalized
significant other and client’s perceptions of feelings regarding
healthcare provider. current situation. anxiety and depression
with significant other
 Encourage significant and healthcare provider
other to spend time with
the client.
 Encourage verbalization
and expression of
feelings towards
depression.
 Be honest when
answering questions or
providing information
 Reviewed past life
experiences and previous
loss, noting strengths and
successes