Nursing Care Plans After Initial Assessment

NURSING SCIENTIFIC GOAL/ NURSING

DATA RATIONALE EVALUATION
DIAGNOSIS BACKGROUND OBJECTIVE INTERVENTION
Subjective: Abdominal Abdominal pain can Long term: INDEPENDENT Goal met. The
“Nagsakit pain related to be mild or severe. It Establish or *Assess pain using *We must have a detailed baseline so patient regained
tiyan ko” as fecal impaction may be continuous regain comfort pain scale. we not only know how to treat comfort and the
verbalized by as evidenced or come and go. It and will not feel appropriately, but also to know if it pain in her
the patient. by abdominal can be short-lived irritability due to has changed. abdomen has been
distention. (acute) or occur over abdominal pain *Record intake and *Patients with abdominal pain may relieved.
Objective: weeks, months or output not be taking in appropriate fluids or
*With sleep years (chronic). Short term: foods, or their urinary and/or bowel
disturbances After 3 hours of output may be lacking.
due to Abdominal pain is nursing *Assess bowel *This is to ensure accurate intake and
abdominal supposed to be a intervention the movements (color, output recording.
pain common complaint patient will consistency,
*Weak in and reason for verbalize that the frequency, amount)
appearance consultation in pain has been *Ensure adequate *Assess and promote appropriate
*Abdominal primary care. It relief and rate it hydration fluid balance, which may requiring
distention affects nearly every using pain scale notifying the provider of a decreased
*Unable to person once in their oral intake and need for intravenous
defacate lifetime independent fluids to maintain fluid balance.
from age, gender and *Assess abdominal *Patients may be experiencing
social background. distention, report abdominal distention as part of the
Abdominal pain can changes in size and underlying disease process
be caused by a broad quality as
spectrum of diseases appropriate
from primarily *Implement *A well-rest often experiences
trivial and self- measures to decrease pain and increased
limited (e.g. promote rest (e.g. effectiveness of pain management
gastroenteritis) to minimize measures.
acute and life- environmental
threatening activity and noise,
conditions (e.g. provide care to

43
abdominal aortic allow for periods
aneurysm) of interrupted rest)

DEPENDENT
*Assist with *For identification of other possible
medical work-up. causative factors.
*Insert nasogastric *Provides decompression and prevents
tube and maintain gas accumulation in the stomach
suction as ordered.
*Administer gastro *It promotes intestinal motility.
intestinal
stimulants if
ordered.
*Administer *Helps minimize the pain that will be
analgesics as experienced.
ordered.

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 NURSING SCIENTIFIC GOAL/ NURSING
DATA RATIONALE EVALUATION
DIAGNOSIS BACKGROUND OBJECTIVE INTERVENTION
Subjective: Constipation Factors involved in Short Term: INDEPENDENT Goal met. The
“Nasakit tiyan ko”, related to constipation originating The patient *Determine fluid intake. *To evaluate client’s patient regained
“Haan nak unay irregular outside the colon include will be able to hydration status. normal pattern
makatakki”; as defecation poor dietary habit (the participate in *Determine access to *To evaluate client’s of bowel
verbalized by the habits; most common factor, bowel program bathroom, privacy, and range of motions and functioning. The
patient. inadequate generally involving as indicated. ability to perform self- perceptions. patient has
toileting as inadequate fiber or fluid care activities. participated in
Objective: evidenced by intake and/or overuse of Long Term: *Investigate reports of *To inspect and bowel program
*Abdominal abdominal pain. caffeine or alcohol), Establish or pain with defecation. determine abnormal as indicated.
distention medications, systemic regain normal Check rectum for findings physically,
endocrine or neurologic pattern of presence of fecal particularly in perianal
diseases, and bowel impaction. areas.
psychological issues. functioning. *Determine laxative or *To report or note signs
enema use. of overuse of stimulant
Constipation results in laxatives.
various degrees of *Palpate abdomen. *To determine for
subjective symptoms and presence of distention,
is associated with masses.
abnormalities (eg, DEPENDENT
colonic diverticular *Assist with medical *For identification of
disease, hemorrhoidal work-up. other possible causative
disease, anal fissures) factors.
that occur secondary to *Identify elements that *To determine usual
an increase in the colonic usually stimulate bowel pattern of elimination.
luminal pressure and activity (caffeine,
intravascular pressure in walking, laxative use)
the hemorrhoidal venous and any interfering
cushions. factors.
*Note color, odor, *Provides a baseline for
consistency, amount and comparison, promotes
frequency of stool. recognition of changes

45
 and to assess current
pattern of elimination.
*Instruct in or encourage *To facilitate return to
a diet of balanced fiber usual or acceptable
and bulk (e.g., fruits, pattern of elimination.
vegetables, and whole
grains) and fiber
supplements (e.g., wheat
bran, psyllium)

COLLABORATIVE
*Encourage or support *To improve organ
treatment of underlying function, including the
medical causes. bowel.

46
 NURSING SCIENTIFIC GOAL/ NURSING
DATA RATIONALE EVALUATION
DIAGNOSIS BACKGROUND OBJECTIVE INTERVENTION
Subjective: Urinary retention The urinary tract Patient empties INDEPENDENT The patient was
“Haan nak related to inability of is designed to bladder *Promote fluids, if not *Unless medically able to empty
makaisbo” as bladder to contract have the urine completely. contraindicated. restricted, fluid intake her bladder
verbalized by adequately as flow from the should be at least 1500 completely.
the patient. evidenced by kidneys, through mL/24 hr.
patient’s the ureters, to the *Place the patient in an *An upright position on a
Objective: verbalization of bladder, and out upright position to commode or in bed on a
*Immobile inability to feel the the urethra. When facilitate successful bedpan increases the
With IFC urge to urinate you have urinary voiding. patient’s voiding success
retention, you through force of gravity.
aren't able to *Encourage the patient to *Voiding at frequent
empty the urine void at least every 4 hours. intervals empties the
from your bladder bladder and reduces risk of
and the urine may urinary retention.
back up into your *Keep indwelling catheter *These provide free
kidneys. patent; maintain drainage drainage of urine,
tubing kink-free. decreasing the possibility of
urinary stasis or retention
and infection.
*Discuss the importance of *Increased fluid stimulates
adequate fluid intake. voiding and decreases the
risk of urinary tract
infections.
*Inform the patient and *Knowledge of the signs
significant other to observe and symptoms allows the
the different signs and patient, significant other, or
symptoms of bladder caregiver to recognize them
distention like reduced or and seek treatment.
lack of urine, urgency,
hesitancy, frequency,
distention of lower

47
abdomen, or discomfort.
DEPENDENT
*Encourage patient to take
bethanechol (Urecholine) *Bethanechol stimulates
as indicated. parasympathetic nervous
system to release
acetylcholine at nerve
endings and to enhance
tone and amplitude of
contractions of smooth
muscles of the urinary
bladder.

48
Nursing Care Plans After Series of Diagnostic Procedures
NURSING SCIENTIFIC GOAL/ NURSING
DATA RATIONALE EVALUATION
DIAGNOSIS BACKGROUND OBJECTIVE INTERVENTION
Subjective: Risk for Fluid and electrolyte Short term: INDEPENDENT Goal met. After
“Haan nak unay electrolyte balance is a dynamic *The patient will *Establish rapport *To easily assess the patient series of
makatakki”, imbalance as process that is be able to have without hesitation interventions, the
“Han nak evidenced by crucial for life and intakes. *Monitor vital signs *To obtain baseline data patient’s level of
makaisbo” as insufficient homeostasis. Fluid *Monitor respiratory *Respiratory muscle weakness serum electrolytes
verbalized by fluid volume. occupies Long term: rate, depth, and may progress to paralysis returned to
the patient almost 60% of the *Patient’s level effort. Encourage deep leading to respiratory arrest. normal range.
*patient’s weight of an adult. of serum breathing and coughing Sodium with
verbalization of Body fluid is located electrolytes will exercise. Encouraged 140.1 mmol/L
loss of appetite in two fluid be at a normal frequent re-positions. and potassium
compartments: range. *Monitor heart rate and *Abnormalities in heart with 3.5 mmol/L.
Objective: the intracellular rhythm conduction and contractility are
*pale looking space and associated with hypokalemia.
*weak in the extracellular Tachycardia may develop as
appearance space. Electrolytes in well as potentially life-
body fluids are threatening atrial and ventricular
active chemicals or dysrhythmias–AV blocks, AV
Serum cations that carry dissociation, ventricular
Electrolytes: positive charges and tachycardia and PVCs.
Sodium – 134.3 anions that carry *Monitor level of *Tetany, paresthesia, apathy,
mmol/L negative charges. consciousness and drowsiness, irritability, and
Potassium – The major cations in neuromuscular function, coma may occur.
2.96 mmol/L the body fluid are noting movement,
sodium, potassium, strength, and sensation.
calcium, magnesium, *Monitor gastric, *Guide for calculating fluid and
and hydrogen ions. urinary, and wound potassium replacement needs.
The major anions are losses accurately.
chloride, *Observe for absence or *Paralytic ileus commonly
bicarbonate, sulfate, changes in bowel follows gastric losses through
and proteinate ions. sounds. vomiting, gastric suction, or

49
 *Discuss preventable protracted diarrhea.
causes of the condition *Provides an opportunity for the
such as nutritional client to prevent a recurrence. In
choices and the proper addition, dietary control is more
use of laxatives. palatable than oral replacement
medications.
DEPENDENT
*Administer IV fluids
as ordered *To rehydrate the patient and
infuse fluid and electrolyte

COLLABORATIVE
*Collaborate in the
treatment of underlying *To prevent, limit, or treat
conditions. effects if electrolyte imbalances
caused by disease or organ
*Consult with dysfunction.
nutritionist/dietician to *Obtaining and utilizing
educate client/SO and to electrolytes and other minerals
recommend or provide are dependent on client
balanced nutrition, receiving them in a readily
using best route for available form. Renal dialysis
feeding as prescribed b for general and specific dietary
condition concerns for client’s needs.

DATA NURSING SCIENTIFIC GOAL/ NURSING RATIONALE EVALUATION

50
 DIAGNOSIS BACKGROUND OBJECTIVE INTERVENTION
Subjective: Activity Decreased oxygen Short term: INDEPENDENT Short term:
“Agkakapsot nak,” as Intolerance capacity of *After 8 hours of *Note client reports *Influence of choice *After 8 hours of
verbalized by the patient. Related to Muscle hemoglobin nursing of weakness, fatigue, interventions nursing
Weakness intervention, the pain, and insomnia. assistance intervention, the
Objective: secondary to patient will be free *Recommended *Enhance rest to patient is free from
*pale looking Decreased Decreased nutrition of getting bed quiet atmosphere; lower body’s oxygen bed sores and
*weak in appearance Hemoglobin level in cells sores and bed rest if indicated requirements and hematomas. Goal
*unable to lift limbs as evidenced by hematomas on the reduces stress on was met.
*prolonged immobilization poor mobilization most prominent heart and lungs
*poor skin turgor sites of the body *Change the position *Changing patient’s Long term:
*Decreased level of Decreased ATP such as the back of the patient every 2 position every 2 *After 2 days of
hemoglobin: 103 g/L production since and buttocks. hours. hours allows good nursing
*Decreased hematocrit oxygen is needed circulation and intervention, goal
level: 0.31 I/I for oxidation of Long term: prevent unwanted was partially met;
glucose *After 2 days of *Monitor laboratory bed sores. *hemoglobin and
nursing tests such as *To identify the hematocrit levels
intervention, the hemoglobin and extent of deficiency are still below
Decreased energy patient will have hematocrit levels. and for better the normal range
or muscle weakness normal *Elevated head of treatment plan. *with good skin
hemoglobin level the bed as tolerated *Enhances lung turgor
from 104 g/L to expansion to
Activity intolerance 130 g/L; maximize
hematocrit level oxygenation for
will increase from *Provided / cellular uptake.
0.31 I/I to 0.40 I/I; recommended *Assisted patient to
*The patient will assistance with prioritize
have good skin activities ADLs/desired
turgor activities.

51
 NURSING SCIENTIFIC GOAL/ NURSING
DATA RATIONALE EVALUATION
DIAGNOSIS BACKGROUND OBJECTIVE INTERVENTION
Subjective: Risk for peritonitis The intestinal Demonstrate INDEPENDENT The patient was
“Nasakit tiyan related to lining becomes use of *Investigate pain reports, *Pain tends to become able to
ko”, as accumulation of swollen and relaxation noting location, duration, constant, more intense, and demonstrate use
verbalized by fluid in abdominal inflamed. If the skills, other intensity(0–10 scale), and diffuse over the entire of relaxation
the patient. or peritoneal cavity condition is not methods to characteristics (dull, sharp, abdomen as inflammatory skills, other
treated, the promote constant). process accelerates; pain may methods to
Objective: intestine can comfort. localize if an abscess develops. promote
*Abdominal rupture, leaking its *Maintain semi-Fowler’s *Facilitates fluid or wound comfort.
distention contents and position as indicated. drainage by gravity, reducing
*Irritability causing diaphragmatic irritation and/or
inflammation and abdominal tension, and thereby
infection of the reducing pain.
abdominal cavity *Move patient slowly and *Reduces muscle tension and
(peritonitis). deliberately, splinting guarding, which may help
painful area. minimize pain of movement.
*Provide comfort *Promotes relaxation and may
measures: massage, back enhance patient’s coping
rubs, deep breathing. abilities by refocusing
Instruct in relaxation and attention.
visualization exercises.
Provide diversional
activities.

DEPENDENT
*Administer medications
as ordered
*Analgesics/Narcotics *Reduce metabolic rate and
intestinal irritation from
circulating or local toxins,
which aids in pain relief and
promotes healing. Pain is

52
 usually severe and may require
narcotic pain control.
Analgesics may be withheld
during initial diagnostic
process because they can mask
signs and symptoms.
*Antiemetics: *Reduce nausea and vomiting,
hydroxyzine (Vistaril); which can increase abdominal
pain.
*Antipyretics: *Reduce discomfort associated
acetaminophen with fever.
(Tylenol).

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 NURSING SCIENTIFIC GOAL/
DATA NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS BACKGROUND OBJECTIVE
Subjective: Risk for fluid Dehydration is Within 8 hours INDEPENDENT Goal met. After
*patient’s volume the decrease in of nursing *Monitor and document vital *Decrease in 8 hours of
verbalizatio deficiency total body water intervention, signs especially the blood circulating blood volume can nursing
n of loss of related to loss content due to patient will be pressure and heart rate. cause hypotension and intervention,
appetite of appetite fluid loss, able to tachycardia. Alteration in HR is patient’s vital
diminished fluid demonstrate a compensatory mechanism to signs were on
Objective: intake, or both. adequate maintain cardiac output. normal values
*Pale- Fluid imbalance hydration as *Assess for signs of dehydration: *Signs of dehydration may also and was having
looking as dehydration or manifested by skin turgor and oral mucous be detected in the skin. Elderly adequate fluid
*Weak in over-hydration is stable vital signs membranes. patient’s skin turgor should be intake showing
appearance associated with and adequate assessed in the sternum as skin adequate
*Limited morbidity and intake of water. losses its elasticity. hydration.
range of mortality *Monitor potential fluid loss *Fluid loss from diarrhea,
motion particularly in drainage such as diarrhea, polyuria, or vomiting may lead
older adults. polyuria, or vomiting. to dehydration.
*Help the patient when unable to *Patient may be weak and may
eat or encourage the significant be unable to meet prescribed
others to assist with feedings. intake.
*Encourage patient to drink *Encouraging the patient to
plenty of water as tolerated or drink plenty of water will keep
based on the patient’s needs. the patient from dehydration.
*Emphasize the relevance of *Informing the patient with
maintaining proper nutrition and regards to nutrition and
hydration. hydration will help in managing
the problem.
DEPENDENT
*Coordinate with the laboratory *Elevated blood urea nitrogen
the serum electrolytes and urine suggests fluid deficit. Urine
osmolality, and report abnormal specific gravity is likewise
values if present. increased.

54
 DATA NURSING SCIENTIFIC GOAL/ NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS BACKGROUND OBJECTIVE
Subjective: Risk for Biologic, Long term goal: INDEPENDENT The patient has
“Nasakit imbalanced psychologic, Demonstrate *Identify client at risk for *To assess causative and/ or demonstrated
tiyan ko”, nutrition: less economic factors. progressive malnutrition. contributing factors. progressive
“Haan nak than body weight gain *Determine client’s ability to *To determine factors that can weight gain
unay requirements toward goal. chew, swallow, and taste food. affect ingestion and/or digestion toward goal and
makatakki”; related to Impair a person’s Evaluate teeth and gums for poor of nutrients. displayed
as inability to ability to ingest or Short term goal: oral health and note denture fit, normalization of
verbalized ingest foods digest food or Display as indicated. laboratory
by the possibly absorb nutrients. normalization of *Ascertain understanding of *To determine informational values in 3
patient. evidenced by laboratory individual nutritional needs. needs of client. weeks.
loss of values within 3 *Discuss eating habits, including *To appeal to client’s likes and
Objective: appetite. Imbalanced weeks. food preferences, dislikes.
*Thin nutrition (less intolerances/aversions.
*Pale than body *Assess drug interactions, *To determine the causes that
requirements) disease effects, allergies, use of may be affecting appetite, food
laxatives, diuretics. intake, or absorption.
*Evaluate impact of cultural, *To determine the causes that
ethnic, religious desires/ may affect food choices.
influences.
*Note age, body build, strength, *Helps determine nutritional
activity or rest level. needs.

DEPENDENT
*Administer IV fluids as ordered
*Administer NGT feeding as
ordered by physician
COLLABORATIVE
*Consult dietitian or nutritional
team, as indicated.
*To maintain fluid and
electrolytes
*To have an alternate way of
feeding without stressing the
patient
*To implement interdisciplinary
team management.

55
Nursing Care Plans After Surgery
NURSING SCIENTIFIC GOAL/ NURSING
DATA RATIONALE EVALUATION
DIAGNOSIS BACKGROUND OBJECTIVE INTERVENTION
Subjective: Acute Pain related to Complex After 12 hours, the INDEPENDENT Goal met. After 12
“Nasakit toy Post-Operative responses of patient’s pain will be *Assess the *Pain must be described hours of
dait ko” as Surgical Incision tissue and nerve lessened. severity of pain by the patient herself in intervention, the
verbalized by endings due to using a pain scale order to plan effective patient’s pain was
the patient trauma from Short Term: with 10 as the most treatment. lessened. She was
surgery and cause *The patient will painful and 0 as the able to characterize
Objective: hypersensitivity verbalize the least painful. her pain and perform
*Presence of to the central characterize the deep breathing
facial grimace nervous system pain. *Teach the proper *To release more exercise.
*On guarding that causes *The client will be deep breathing endorphins and enhance
position unpleasant able to perform pain technique the therapeutic effects of
physical and management, such pain relief medications.
emotional as proper deep
reactions and breathing technique. DEPENDENT *Analgesics help numb
responses. *Administer the pain.
Long Term: analgesics as
The patient will be ordered by the
able to move without physician
pain.

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 NURSING SCIENTIFIC NURSING
DATA GOAL/OBJECTIVE RATIONALE EVALUATION
DIAGNOSIS BACKGROUND INTERVENTION
Subjective: Risk for Infection Risk for infection GOAL INDEPENDENT Goal met. After 8 hours
“Nasakit toy related to is one of the Patient remains free of *Note risk factors *To help the patient of nursing intervention,
dait ko” as Post-Surgical common infection, as for occurrence of identify present risk the patient was able to
verbalized by Incision possibly problems of an evidenced by normal infection in the factors that may lead meet the goal with an
the patient evidenced by individual, which vital signs and incision to infection evidence of the signs and
increased level of has an alteration absence of signs and *Regularly check *Fever is a possible symptoms of infection
Objective: neutrophils or disturbance in symptoms of infection temperature sign of infection
the immune
The patient *Observe for *To evaluate the
defenses.
has a surgical Short Term: localized of character, presence,
Microorganisms
incision at the *Identify risk factors infection at the and condition of
enter and invade
right lumbar *Have partial surgical wound infection
the body which
region understanding about *Educate the *To help the client
later on causes
different kinds of infection control patient in modify and avoid
Neutrophil infections. identifying risk some of the factors
Level – 83.6% factors that could present which could
The patient also is Long Term:
lead to infection reduce the incidence
diabetic which *Patient is of infection
makes wound knowledgeable in
healing difficult. identifying risk factors DEPENDENT
for infection *Administer *Antibiotics will help
antibiotics as kill and stop the
*Be free from any
ordered by the proliferation and
signs and symptoms
physician growth of the bacteria
related to infection
which could cause
infection

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