Nursing Care Plan

Student’s name: Unit: High risk

Patient’s name: Date:
Diagnosis: Fluid volume excess (edema) Group:
Assessments Nursing Diagnosis Goals Nursing Interventions Evaluation
Subjective: Fluid volume Treat or 1- Take vital signs Patient
Patient said: “I excess related to prevent fluid 2- Review patient’s history to determine maintains the
feel hormonal volume the probable cause of the fluid imbalance. normal fluid and
enlargement of disturbances or excess. electrolyte
my hands and severe stress 3- Monitor input and output closely. balance within 6
foot” evidence by Regain fluid 4- Note for presence of edema by hours from
Objective: sudden swelling of balance, as palpating over the tibia, ankles, feet, and nursing
Pitting edema is general body evidenced by sacrum. interventions.
+4 weight loss, 5- Limit sodium intake as prescribed.
decreasing 6- Note presence of medical condition that
edema, and potentiate fluid excess
normal vital 7- Assess degree of peripheral edema.
signs. 8- Assessment of patient’s health and
general condition.
9- Position of patient must be changed to
prevent pressure sores.
 Nursing Care Plan
Student’s name: Unit: High risk
Patient’s name: Date:
Diagnosis: Fatigue Group:
Assessments Nursing Diagnosis Goals Nursing Interventions Evaluation
Subjective: Fatigue related to Relief fatigue 1- Evaluate the patient’s description of After 3 hours of
Patient said: “I physical factors and maintain fatigue: severity, changes in severity over nursing
feel tired” evidence by comfortable time, aggregating factors or alleviating interventions
Objective: patient’s environment factors. the patient
Patient look condition. for the 2- Provide comfort such as judicious touch reported
very tired from patient. or massage, and cool showers. improved sense
pregnancy 3- Encourage verbalization of feelings of energy.
about the impact of fatigue.
4- Provide emotional support.
5- Assess the patient’s routine.
recommendation and over-the-counter
drugs.
6- Encourage an exercise conditioning
program as appropriate.
 Nursing Care Plan
Student’s name: Unit:
Patient’s name: Date:
Diagnosis: Risk for infection Group:
Assessments Nursing Diagnosis Goals Nursing Interventions Evaluation
Subjective: Risk for infection Remain free 1- Take vital signs specially temperature The patient and
- maybe related to environment 2- Assess the skin for color, texture, elasticity, environment
Objective: hospitalization from signs of and moisture. are free from
3- Routinely monitor the patient’s complete
Changes of vital any infection blood count.
any infections
signs Demonstrate 4- Take note of the patient’s current
ability to medications.
perform 5- Check the patient’s immunization history.
hygienic 6- Wash hands and encourage the patient to do
measures, the same. Dry hands with a paper towel after
like proper washing.
7- Encourage patient to increase fluid intake.
oral care and 8- Encourage patient to eat a balanced diet.
handwashing 9- Help patient change positions frequently.
10- Allow the patient to stay in a private room.
11- Limit the use of common equipment. If that
isn’t possible, make sure to disinfect it before
using on another patient.
 Nursing Care Plan
Student’s name: Unit:
Patient’s name: Date:
Diagnosis: Impaired comfort Group:
Assessments Nursing Diagnosis Goals Nursing Interventions Evaluation
Subjective: Impaired Make 1- Maintain a calm and quiet Express
Patient said: “I comfort related patient environment. reduction of
feel tired” to illness and comfort as 2- Use of relaxation technique such discomfort
Objective: treatments possible as: cold and heat application and Appear
Patient can’t evidence by deep breathing exercise. relaxed able
move and lie feeling of 3- Provide distraction techniques such to rest
in bed. discomfort as music, television, or massage. appropriately
4- Teach techniques to use when
client is uncomfortable including
relaxation techniques, guided
imagery, hypnosis, and music therapy.
5- Assessing client’s level of comfort
on an hourly basis
 Nursing Care Plan
Student’s name: Unit:
Patient’s name: Date:
Diagnosis: Hyperthermia Group:
Assessments Nursing Diagnosis Goals Nursing Interventions Evaluation
Subjective: Maintain 1- take vital signs and monitor the After 1 hour of
Patient said: “I Hyperthermia patient’s temperature. nursing
feel burn in my related to sever body 2- provide comfortable environment. interventions,
back and pain in abdomen temperature 3- Adjust and monitor environmental the patient’s
abdomen” and back evidence below factors like room temperature and bed temperature
Objective: by temperature of 38.5° C linens as indicated. was decreased
Body patient is 38.5° C 4- Eliminate excess clothing and covers. from 38.5° C to
temperature 6- Give antipyretic medications and cold 36.7° C
elevated above drinks as prescribed.
normal range, 7- Encourage ample fluid intake by mouth.
it’s 38.5° C 8- Provide high caloric diet or as indicated
by the physician to meet the metabolic
demand of the patient.
9- Educate patient and family members
about the signs and symptoms of
hyperthermia and how to prevent it.
 Nursing Care Plan
Student’s name: Unit:
Patient’s name: Date:
Diagnosis: Ineffective breathing pattern Group:
Assessments Nursing Diagnosis Goals Nursing Interventions Evaluation
Subjective: Patient’s 1- Take vital signs. The patient was
- Ineffective breathing 2- Assess respiratory rate and depth by able to establish
Objective: breathing pattern pattern is listening to lung sounds. a normal
Irregular related to pain maintained 3- Monitor breathing patterns breathing
breathing evidence by as evidenced 4- Assess position patient assumes for pattern and
pattern and irregular in by eupnea, normal or easy breathing. breathing
abnormal respiration rate normal skin 5- Use pulse oximetry to monitor oxygen sounds
breathing color, and saturation and pulse rate.
sounds regular 6- Encourage the patient to do deep
respiratory breathing exercise.
rate/pattern. 7- Assess presence of sputum for quantity,
color, consistency.
8- Provide respiratory medications and
oxygen, per doctor’s orders.
9- Avail a fan in the room, moving air can
decrease feelings of air hunger.