8/2/2019 NCP_FINAL

1/18

CHAPTER 8

NURSING CARE PLAN

ASSESSMENT DIAGNO SIS PLANNING INTERVENTION RATIONALE EVALUATIONSUBJECTIVE:Nganongperme komalipung asverbalized bythe pt.

OBJECTIVE:-requestinformation-agitatedbehavior-inaccuratefollow throughof instructions.

-VS taken as

followT: 38.4P: 105R: 23BP: 160/100

Risk forpronebehavior r/tlack ofknowledgeabout thedisease.

After 4 hours ofnursinginterventionpatient willverbalizedunderstanding ofdisease,process and

treatmentregimen.

>Defined andstated the limitsof desired BP,explainhypertension andits effect on theheart, bloodvessels, kidney

and brain.

>Assisted thepatient inidentifyingmodifiable riskfactors like highsodium diet,

saturated fatsand cholesterol.>Reinforced theimportance ofadhering thetreatmentregimen andkeeping follow upappointment.

>Provides basesforunderstandingelevations ofBlood pressure,and clarifiesmisconceptionsand also

understandingthat BP can existwithoutsymptoms oreven whenfeeling well.>These riskfactors havebeen shown tocontribute to

hypertention.

>Lack ofcooperation iscommon reasonfor failure of antihypertensive

Goal met-After 4 hours ofnursingintervention thepatient was ableto verbalizedunderstanding ofthe disease

process &treatmentregimen.

8/2/2019 NCP_FINAL

2/18

>Suggestfrequent positionchanges, legexercises when

lying down.

>Help patientidentify sourcesof sodium intake.

>encouraged

patient todecrease oneliminate caffeinelike in tea ,coffee, cola andchocolates.>Stressedimportance ofaccomplishingdaily rest periods.

DEPENDENT:>Provideinformationregardingcommunityresources and

therapy.

>Decrease

peripheralvenous poolingthat maybepotentiated byvasodilators andprolonged sittingor standing.

>Two years ofmoderate low

salt diet maybebe sufficient tocontrolhypertension.>Caffeine is acardiac stimulantand adverselyaffect cardiacfunction.

>Alternating restinactivityincreasestolerance toactivityprogression.

8/2/2019 NCP_FINAL

3/18

support patientsin making lifestylechanges.

>Communityresources likehealth centerprograms and

check ups arehelpful incontrollinghypertension.

8/2/2019 NCP_FINAL

4/18

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE:

- wala pako

naka libang

sugad ganina

buntag

OJECTIVE:

- Decreased

ambulation of

the patient bcs

of pain and the

complete bed

rest ordered of

the physician.

constipation

related to

voiding

incontinence.

After 4 hrs of

nursing

intervention,

the patient will

verbalize

understanding

the etiology and

appropriate

intervention if

constipation

may occur.

- Educate patient/

SO about safe and

risky practices for

managing

constipation.

- Instruct balance

fiber and bulk in

diet and fiber

supplements.

- Promote

adequate fluid

intake, also

- Information can

help client to make

beneficial choices

when need arises.

- To improve

consistency of stool

and facilitate

passage through

colon.

- To promote soft

stool and stimulate

Goal Met

the patient verbalized

understanding about

constipation and gained

knowledge of appropriate

intervention.

8/2/2019 NCP_FINAL

5/18

suggest drinking

warm fluids.

- Encourage

activity within

limits of individual

ability.

bowel activity.

-To stimulate

constrictions of the

intestines

8/2/2019 NCP_FINAL

6/18

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONSUBJECTIVE:muragnagabug`at man

ang akongtimbang asverbalized by thepatient.

OBJECTIVE:-variations in BP-edema-VS taken as

followsT: 37.5P: 87R: 22BP:120/100

Decreasedcardiac output r/tdecreased

venous return

After 6 hours ofnursingintervention the

patient willparticipate inactivities thatreduce bloodpressure orcardiac workload.

INDEPENDENT:>Monitor bloodpressure of the

pt. Measure inboth arms orthigh three time,3-5 minutes apartwhile pt is at rest,then standing forinitial evaluation.>Observe, skin,color, moisture,temperature &

capillary time

>Note dependentor general edema

>provide calm,rest fullsurroundings,minimizeenvironmentalactivity or noise.>Maintain activityrestrictions

>Instruct inrelaxation &

>Comparison ofpressures a more

complete pictureof vascularinvolvement orscope of theproblem.

>Presence ofpallor, cool, moistskin, & delayed

capillary refill timemaybe due toperipheralvasoconstriction>May indicateheart failure renalor vascularimpairment.>Help reducesympatheticstimulation,promotesrelaxation

>Reducesphysical stress &tension that affectblood pressure &course of

Goal metAfter 6 hours ofnursing

intervention thepatient was ableto participate inactivities thatreduce bloodpressure orcardiacworkload.

8/2/2019 NCP_FINAL

7/18

guided imagery.

DEPENDENT:>Implementdietary sodium,fat, & cholesterolrestrictions asindicated

hypertension>Can reducestressful stimuliproduce calming

effect, therebyreduce bloodpressure.

>Theserestrictions canhelp manage fluidretention & withassociatedhypertensive

response, whichdecrease cardiacworkload.

8/2/2019 NCP_FINAL

8/18

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

Luya kaayo

akong paminaw.

Maski sige lang

ko ug tulog kay

kapoie gihapon

akong ginabati

as verbalized by

the patient.

Objective:

=Weakness

=Lack of energy

=Pale skin

=Decreased

muscle strength

Fatigue

related to

poor physical

condition

At the end of 1

day span of

nursing care, the

patient will be

able to:- report

improved sense

of energy-

perform ADLs-

participate in

desired activities

at level of ability

1. Teach energy

conservation

principles.

2.Stress the

importance of

frequent rest

periods

3. Observe the

patient usual level

1.Patients and care

giver may need to

learn skills for

delegating tasks to

others, setting priorities

and clustering care to

use available energy to

complete desired

activities.

2. Energy reserves

may be depleted

unless the patient

respects the body

need for increased

rest.

3. Both increased

physical exertion and

At the end of 1 day

span of nursing

gcare, the patient

was able to:-

Report improved

sense of

energyArang-

arang na akong

paminawas

verbalized by

patient.

8/2/2019 NCP_FINAL

9/18

of exercise and

physical activity.

4. Assist the

patient to develop

a schedule for

daily activity and

rest.

limited levels of

exercise can contribute

to fatigue.

4. A plan that balances

periods of activity with

periods of rest can

help the patient

complete desired

activities without

adding to levels of

fatigue.

8/2/2019 NCP_FINAL

10/18

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:

Sakit kaayo ang

akong tiyan sa

bandang baba

as verbalized by

the patient.

Objective:

=Grimaced face

noted

=Narrowed focus

guarding

behaviour

=pain scale of 7

out of 10.

Acute pain r/t

to epigastric

pain

After 2hrs. span

of care patient

pain will be

relief or

controlled as the

evidence of pain

scale 7 out of

10.

1.observed and

document location

of the pain, scale(0-

10) and character of

pain.

2.Promote bed rest.

3.Encourage of use

relaxation

techniques.

4.Control

environmental

pressure.

5.Administered

medication as

physician ordered.

1.Provide

information about

disease

progression,

development of

complication and

effectiveness of

intervention

2.To reduce intra-

abdominal pressure

3.To promote rest

,redirect attention,

may enhance

coping.

4.To minimize

dermal discomfort.

After 2hrs. span of

care patient pain

was relief and

controlled as the

evidence of pain

scale of 3 out of

10.

8/2/2019 NCP_FINAL

11/18

5.To reduce severe

pain, promotes and

relax smooth

muscle.

8/2/2019 NCP_FINAL

12/18

ASSESSMENT DIAGNOSIS PLANNNING INTERVENTION RATIONALE EVALUATION

Subjective:

Naga luya ko

pero dali lang

kaayo ko

kapuyon as

verbalized by the

patient.

Objective:

=Body malaise

noted

= look tired

=pale skin noted

=With fatigability

Risk for Activity

in Tolerance r/ t

body weakness

After 8hrs of

nursing

intervention the

patient will

Report an

increase an

activity in

tolerance

including

activities of daily

living.

Assess patients

ability to perform

normal task or

activities of daily

living.

Note changes in

balance/ gait

disturbance,

muscle weakness.

Recommend quiet

atmosphere, bed

rest if indicated.

Influences choice of

interventions or

needed assistance

May indicate

neurological changes

associated with

vitamin

B12deficiency,

affecting patient

safety or risk of

injury.

Enhances rest to

lower bodys oxygen

requirements, and

reduces strain on the

heart and lung

After 8hrs of

nursing

intervention the

patient was able to

reveals an

increase inactivity

tolerance.

8/2/2019 NCP_FINAL

13/18

Elevate the head of

the bed as

tolerated.

Provide or

recommend

assistance with

activities or

ambulation as

necessary, allowing

patient to do as

much as possible

Enhances lung

expansion to

maximize

oxygenation for

cellular uptake.

Although help maybe

necessary, self

esteem is enhanced

when patient does

some things for self.

8/2/2019 NCP_FINAL

14/18

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONSUBJECTIVE:Init kayo kayodire ma`am

sabah pa jud asverbalized

OBJECTIVE:>irritability>elevated bloodpressure>VS taken asfollowT: 38.4P:R:BP:140/90

Risk for seizurer/t environmentalfactor & stressor

After 1 hour ofnursingintervention the

patient will ableto understandthe risk factor ofseizure.

>Encouragedverbalization offeelings &

perceptionregarding herpresentCondition.>Educate clientregarding riskfactors of seizure>Determinedfactors r/tindividualsituation, as listedin risk factor, &extent of risk.>Assessinfluence ofclients lifestyle &stress onpotential forseizure.>Revieweddiagnostic studies& laboratory testfor imbalances.>provided seizureprecaution.>Kept bed in lowposition asappropriate.>Encouraged

>To assess theknowledge of thepatient regarding

her presentcondition.

>Able todemonstrateunderstandingfor her benefit.>Influencesscope and ofinterventions tomanage threat tosafety.

>That may resultin or exacerbateconditions.

>to prevent injuryor fall if seizure

Goal MetThe patientdemonstrate and

able to verbalizeunderstandingregarding the riskor the factorsthat may lead toseizure.

8/2/2019 NCP_FINAL

15/18

divertionalactivities such aschatting to otherpatient`s.

>providedcomfort.

occur.>To divert herattention andlessen stressors.

>for patientscomfort

8/2/2019 NCP_FINAL

16/18

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONSUBJECTIVE:wala ko kaihisukad gahapon

OBJECTIVE:- low urine

output for8 hours100cc

- with folycatheter

- edema

Urinalysis:Color: LightYellowAppearance:ClearReaction: 8Specificgravity: 1.05PUS CELL:0-5Sugar: (-)Albumin: (+)Protein: +3(0.5g)

Impaired urinaryelimination

After 4 hours ofnursingintervention the

patient willachieve normalurine eliminationpattern orparticipate inmeasure tocorrect orcompensate fordeffects.

>Determinedclient usual dailyfluid intake. Note

condition of skinin mucusmembranes,color of urine.>Ascertainclients previouspattern ofelimination.>Have clientkeep a voidingdairy for 3 daysto record fluidintake, voidingtimes, preciseurine output, indietary intake.>Encourage fluidintake up to3000cc or moreper day,includingcranberry juice.

>Checkfrequently for

>To helpdetermined levelof dehydration.

>For comparisonwith currentsituation.>helpsdeterminedbaselinesymptoms,severity offrequency orurgency, inwhether diet is afactor.

>To helpmaintain renalfunction, preventinfection andformation ofurinary stones,avoidencrustationaround catheter,or flushingurinary diversionappliance.

Goal PartiallyMet

The patient wasable tocompensate butnormal urineeliminationpattern was notachieved.

8/2/2019 NCP_FINAL

17/18

bladderdistention andobserve foroverflow

To reduce risk ofinfection and/orautomatichyperrelfexia.

8/2/2019 NCP_FINAL

18/18

Assessment NursingDiagnosis

Planning Intervention Rationale Evaluation

Subjective:nagainitakoang lawas,mura man kuggi hilantan oi,kapoy pa gyudmu lihok Asverbalized bythe patient

Objective:

Dry skinWarm to touchDry lipsIrritableTemp: 38.4

Hyperthermiarelated toinvasion ofinfection.

After 4 hours ofcompleting thenursingintervention, thepatients bodytemperaturemust fall withinthe normalrange of 37.4

Independent:Establish Rapport

Health teaching to thewatcher regarding theproper way of takingcare of the patientwhile on hyperthermia

Apply TSBPromote surfacecooling by looseningthe clothesAssess fluid loss andfacilitates oral fluidintake to accomplishfluid replacement

Dependent:

AdministerParacetamol asprescribed.

To gain trust

To educate andsupplyinformation

Promote heat lossby evaporationand conductionIncreasemetabolic rateand diaphoresisassociated withfever

Medicine toreconcile rise oftemperature.

After 2 days ofperformingintervention, goalwas partially met,the watcher hasgainedknowledge abouthyperthermiaand the patientsbodytemperaturedecreased from38.4 to 37.4