XIV.

NURSING CARE PLAN

Patient’s Name: Patient B Hospital No. : 11111

Age: 18 Diagnosis: Allergies
Room No. 2 Attending Physician: Dr. T
Student/Placement: Date:

NSG. DX. RATIONALE

CUES NEED W/SCIENTIFIC OBJECTIVE OF NSG. ACTION EVALUATION
BASIS CARE
O: Disturbance After 8 hours of
● Assisted sleep pattern ● High percentage of
sleeping nursing intervention, After 8 hours of nursing
⮚ Restlessness disturbance that are sleep disturbance are intervention.
pattern related the client will be able
to skin rashes. to: associated with affected by illness
⮚ Irritability
specific underlying ●The patient will be
illness. able to report y hours of
VS: BP- 110/80 ● The patient ● To determine usual
sleep that day.
BT- 36.2 was able to sleep pattern and
PR- 120bpm achieve provide appropriate ● Goal met.
RR- 30bpm ● Observed and intervention
optimal
SPO2- 89% amount of obtained feedback
sleep as from client regarding
● So that patient will
evidinced by usual
bedtime,routines hour have an
rested
of sleep and understanding of the
apperance
invironmental needs. importance of care
verbalization
being done.
of feeling ● Explained necessity of
rested and
disturbance for
improvement
monitoring vs and
in sleeping
care for hospitalized.
pattern.
Patient’s Name: Patient A Hospital No. : 11111
Age: 18 Diagnosis: Allergies
Room No. 2 Attending Physician: Dr. T
Student/Placement: Date:

NSG. DX. RATIONALE

CUES NEED W/SCIENTIFIC OBJECTIVE OF NSG. ACTION EVALUATION
BASIS CARE
O: Impaired skin After 8 hours of Goal partially met
● Complete skin ● A thorough head-to-toe
integrity related nursing intervention, After 8 hours of nursing
⮚ Flushing of the skin assessment skin assessment should
to food allergic the client will be able intervention.
reaction as to: be performed on
⮚ swelling
evidence by admission to prevent
skin breakdown. ● The client
⮚ observed scratching skin rashes
● Now the effect demonstrate the
⮚ fatigue of eating effect in eating
● Assess site of ● To check integrity
allergic food allergic food
reaction to her redness, swelling monitor progress of
body and areas of itching healing
● The patient
Identify signs and
● Identify signs ● Educate patient of
symptoms in
proper allergic food ● Patient now the food
and symptoms avoiding allergic
in avoiding reaction on her allergies reaction of food reaction
allergic food body shrimp in her body
reaction
● Instruct patient and
watcher to refrain ● To avoid accumulation of
from moisture at the operative
touching/scratching site this may lead to skin
operative site breakdown
● Monitored vital sign
● Serve as baseline data

● Allergy testing as ● Testing for food allergies

order often includes skin
testing and/or blood tests

● Encourage the ● To allow continuous

patient to verbalized monitoring and
the feeling of assessment of patient
inching and condition
reediness
discomfort as well
as changes noted
on operative site.

● Instructed proper ● Proper hygiene will

hygiene and self- prevent infection and
care as well in her complication. A clean
surrounding environment occurrence
of any disease

● Encourage ● This is to prevent fatigue

adequate rest
period

● Administer ● Administering
medications as medications such as
ordered analgesics will help in
pain relief.
Patient’s Name: Patient B Hospital No. : 11111
Age: 18 Diagnosis: Allergies
Room No. 2 Attending Physician: Dr. T
Student/Placement: Date:

NSG. DX. RATIONALE

CUES NEED W/SCIENTIFIC OBJECTIVE OF NSG. ACTION EVALUATION
BASIS CARE
O: Ineffective After 8 hours of Goal partially met
● Administered oxygen ● Adequate
airway nursing intervention, After 8 hours of nursing
⮚ Difficulty of breathing as ordered oxygenation facilities
clearance the client will be able intervention.
related to to: gas exchange and
⮚ Watery eye
allergies perfusion ●The patient airway
⮚ fatigue ● Assessed patient vital patency
● The patient
● To assist in creating improved and the improve
was able to sign and characteristic
VS: BP- 110/80 airway clearance as
maintain of respirations at least an accurate
BT- 36.2 manifested by normal
airway patency every 2 hours diagnosis and
PR- 120bpm respiratory rate between 16-
And improved monitor effectiveness
RR- 30bpm 20
airway of medical treatment
SPO2- 89% ● Patient demonstrate
clearance as ● Assist the patient to
manifested by ● To promote for an appropriate coping
an optimal upright
normal behavior
position ideal body alignment
respiratory
for maximum lung
rate between
expansion
16-20
 ● Encouraged to do ● Promote chest
deep breathing expansion
● Demonstrate exercise.
appropriate
● Rest periods relieve
coping
● Provide rest periods undue fatigue that
behavior
with a calm may inhibit effective
environment. weaning.
● Clear breath sounds
● Auscultate breath indicate a patent
sounds. airway.
● The patient may
● Monitor respiratory manifest tachypnea
patterns such as rate, due to the
depth, and effort. obstruction caused
by the secretions in
the airway as the
allergic reaction.

● Arterial blood gases

● Monitor blood gas revealing hypoxemia
values and pulse or hypoxia and less
oxygen saturation. than 90% oxygen
saturation indicate
poor oxygenation
caused by ineffective
clearance.

● Assess for ● Dehydration causes

dehydration. mucus to thicken and
makes clearing the
airway harder.

● Drinking plenty of
 fluids thins secretions
● Encourage fluid
and prevents
intake. dehydration. Instruct
patients to drink 2L of
water a day if not
contraindicated.

● Reduce airway
● Administer
resistance and
medications as improve breathing
needed effort.

Patient’s Name: Patient B Hospital No. : 11111

Age: 17 Diagnosis: Allergies
Room No. 2 Attending Physician: Dr. T
Student/Placement: Date:

NSG. DX. RATIONALE

CUES NEED W/SCIENTIFIC OBJECTIVE OF NSG. ACTION EVALUATION
BASIS CARE
✔ To assess readiness
O: Risk for prone After 30 minutes of Ascertain level of knowledge, Goal met.
After 30 minutes of nursing
behavior nursing intervention including anticipatory needs.
Inaccurate follow through of to learn. intervention.
related to lack the patient will be able
instruction
of knowledge to participate in Provide positive
After 30 minutes of nursing
VS: BP- 110/80 about disease. learning process reinforcement. ✔ Can encourage
intervention the patient was
BT- 36.2
continuation of able to participate in
PR- 120bpm
RR- 30bpm Determine clients most efforts.
SPO2- 89% urgent need from both clients learning process.
and nurse viewpoint.
✔ Which may differ and

require adjustment in
State objectives clearly in
teaching plan.
learner’s terms

Determine client’s method of ✔ To meet learner’s

accessing information. need.

Provide mutual goal setting

✔ To facilitate learning
and learning contacts.
or recall.

Provide access information

for contact person. ✔ Clarifies expectations

of teacher and
Provide access information learner.
about additional learning
resources.
✔ To answer question

and validate
information post
discharge.

✔ May assist with

further learning and

promote learning at
own pace.
Patient’s Name: Patient B Hospital No. : 11111
Age: 18 Diagnosis: Allergies
Room No. 2 Attending Physician: Dr. T
Student/Placement: Date:

NSG. DX. RATIONALE

CUES NEED W/SCIENTIFIC OBJECTIVE OF NSG. ACTION EVALUATION
BASIS CARE
Risk for allergy After 8 hours of * Provide educational Allergic reaction range from After 8 hours of nursing
O:
response nursing intervention; resources and assistance for skin irritation of anaphylaxis. interventions:
Dry skin related to number for emergencies Reaction may be gradual
Redness eating the patient will but progressive affecting
restricted food understanding multiple body systems or the patient was
individual risk and * Identify the client causative may be sudden, requiring understanding individual
VS: BP- 110/ 80 responsible in precipitating factor related to life savings treatment risk and responsible in
BT- 36.2
avoiding exposure. risk avoiding exposure. Identify
PR- 120
RR- 20 Identify sign and sign and symptoms
SPO2- 89%
symptoms requiring * Identify the symptoms of * When allergy suspected or requiring prompt response.
prompt response. clients and report history of the potential for allergy exist
allergy protection must begin with
identification and removal of
possible resources
* Allergies can manifest as
local reaction client may be
aware of some symptoms