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B. NURSING CARE PLAN
1. NURSING CARE PLAN FOR ACUTE PAIN
CUES NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBEJECTIVE INTERVENTION RATIONALE EVALUATION
Subjective:
The client
verbalized,” Ang
masakit lang sa
akin ngayon ay
yung tahi ko.”
Objective:
Patient’s
pain scale
score is 4
(Moderate
Pain)
Acute Pain
r/t surgical
incision
In the past, pain
control was a
major problem
after cesarean
birth. Pain was
so intense from
the uterine or
abdominal
incision that it
interfered with a
woman’s ability
to move and
deep breathe.
LONG TERM:
After the
nursing
intervention,
the client will
be able to
have a
reduced pain
in the pain
scale of 2.
SHORT
TERM:
INDEPENDENT:
1. Assess vital
signs.
2. Encourage
verbalization of
feelings about
the pain.
3. Provide
additional
comfort
measures; e.g.
back rub, heat/
1. Changes
in these vital
signs often
indicate
acute pain
and
discomfort.
3. Improves
circulation,
The client’s
pain has been
reduced to
pain scale of
2.
Facial
grimace
(Source:
Maternal and
Child Health
Nursing by
Adelle Pillitteri)
After the
nursing
intervention
the client will
be able to
apply nursing
intervention
intended to
improve
condtion.
cold
applications.
4. Encourage
use of relaxation
techniques; e.g.
deep breathing
exercises.
5. Encourage
adequate rest
periods.
DEPENDENT:
6. Administer
analgesics as
reduces
muscle
tension and
anxiety
associated
with pain.
Enhances
sense of well-
being.
4. Relieves
muscle and
emotional
tension
enhances
sense of
control and
may improve
coping
abilities.
indicated to
maximal dosage
as needed.
7. Provide
around the clock
analgesia with
intermittent
rescue doses.
5. To prevent
fatigue.
6. To
maintain
“acceptable”
level of pain.
7. Research
supports
need to
administer
analgesics
around the
clock initially
to prevent
rather than
merely threat
pain.
2. NURSING CARE PLAN FOR HYPERTHERMIA
CUES NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIO
N
OBJECTIVE
S
INTERVENTION
S
RATIONALE EVALUATIO
N
Subjective:
The client
verbalized,
“Mainit ang
pakiramdam ko.”
Objective:
Hyperthermi
a r/t Trauma
In a fever, the
set point of the
hypothalamic
thermostat
changes
suddenly from
the normal
level to a
higher value as
LONG
TERM:
After the
nursing
intervention
the client will
be able to
maintain core
INDEPENDENT:
1. Monitor the
client’s
temperature.
Note shaking
chills/profuse
diaphoresis.
1. The temperature
of 102°F-106°F
(38.9°C-41.1°C)
suggests acute
infectious disease
process. Fever
pattern may aid in
The client
was able to
maintain core
temperature
within normal
range after
the nursing
interventions.
Warm to
touch
Flushed
skin
Measurement:
T 38° C
a result of the
effects of
tissue
destruction,
pyrogenic
substances, or
dehydration on
the
hypothalamus.
(Source:
Fundamentals
of Nursing 7th
Edition, by
Kozier, page
488)
temperature
within normal
range.
SHORT
TERM:
After the
nursing
intervention
the client will
be able to
apply the
interventions
intended to
improve
condition.
diagnosis; eg.
sustained or
continuous fever
curves lasting
more than 24
hours suggest
pneumoccocal
pneumonia, scarlet
of typhoid fever;
remittent fever
(varying only a few
degress in either
direction) reflects
pulmonary
infections;
intermittent curves
or fever that
returns to normal
once in 24 hour
period suggests
septic episode,
2. Monitor
environmental
temperature,
limit/add bed
lines as
indicated.
3. Provide tepid
sponge baths,
avoid use of
alcohol.
septic endocarditis
or tuberculosis
(TB). Chills often
precede
temperature
spikes.
2. Room
temperature/numb
er of blankets
should be altered
to maintain near-
normal body
temperature.
3. May help reduce
fever.
DEPENDENT:
4. Administer
antipyretics.
4. Used to reduce
fever by its central
axon on the
hypothalamus;
fever should be
controlled in clients
who are
nuerotropenic or
asplenic.
However, fever
may be beneficial
in limiting growth of
organisms or
enhancing
autodestruction of
infected cells.
3. NURSING CARE PROCESS FOR DISTURBED BODY IMAGE
CUES NURSING
DIAGNOSI
S
SCIENTIFIC
EXPLANATIO
N
OBJECTIV
E
INTERVENTIO
N
RATIONALE EVALUATIO
N
Subjective:
As verbalized by the
client, “ feeling ko ang
taba-taba ko.”
Objective:
verbalization of
negative
feelings about
one’s self.
Disturbed
Body Image
r/t
Pregnancy
If we examine
our lives as
women, we can
see several
patterns of
emotional
crises. All the
periods---the
appearance of
menarche,
pregnancy, &
postpartum
recovery &
menopause---
are marked by
LONG
TERM:
After the
nursing
intervention,
the client
will be able
to recognize
&
incorporate
changes
into self-
concept
without
negating
INDEPENDENT
:
1. Discuss
meaning of
change to client.
2. Have client
describe self,
noting what is
positive & what
is negative.
1. A change in
function may
be more
difficult for
some to deal
with than a
change in
appearance.
2. To develop
new &
creative
solutions.
The client
was able to
recognize &
incorporate
changes into
self-concept
without
negating self-
esteem.
extraordinary
changes in
body image.
These
significant
changes in the
body are
almost always
accompanied
by
corresponding
emotional
changes.
(Source: “The
complete
postpartum
guide.”
p.43
By: Diane
Lynch-Fraser.)
self-esteem.
SHORT
TERM:
After the
nursing
intervention,
the client
will be able
to apply the
intervention
intended to
improve
condition.
3. Listen to
client without
comments &
responses to
the situation.
4. Visit client
frequently &
acknowledge
the individual as
someone who is
worthwhile.
5. Make time to
sit down &
talk/listen to
client while in
3. Different
situations are
upsetting to
different
people,
depending on
individual
coping skills &
past
experiences.
4. Provides
opportunities
for listening to
concerns &
questions.
the room.
6. Help client to
select & use
clothing &
make-up.
7. Refer to
therapist or
counselor as
needed.
5. To
decrease
sense of
isolation or
loneliness.
6. To
minimize body
changes &
enhance
appearance.
7. Helpful in
identifying
ways/ devices
to regain &
maintain
independence
. Client may
need further
assistance to
resolve
persistent
emotional
problems.
4. NURSING CARE PROCESS FOR IMPAIRED SKIN INTEGRITY
CUES NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
GOAL AND
OBJECTIVE
INTERVENTION RATIONALE EVALUATION
Subjective:
The client verbalized
“Sumasakit yong
tahi ko kapag
Impaired skin
integrity
related to
surgery
The skin serves
as the primary
line of defense
against
bacterial
invasion. When
LONG
TERM:
After the
nursing
intervention,
INDEPENDENT:
1. Assess skin
daily. Note
color, turgor,
circulation and
1.
Establishes
comparative
baseline
After the
nursing
intervention,
the client able
to improved
gumagalaw ako.”
Objective:
Presence of
surgical
incision
skin is incised
for a surgical
procedure, this
important line of
defense is lost
(Source:
Maternal and
Child Health
Nursing,
Pillitteri p.567)
Surgical
incisions heal
by primary
intention or by
the gradual
removal and
replacement of
dead or
damaged cells
the client will
be able to be
free
of/display
improvement
in wound
lesion
healing.
SHORT
TERM:
After the
nursing
intervention,
the client will
be able to
apply
The
Intervention
intended to
sensation.
Describe
measure lesions
and observe
changes.
2.
Maintain/instruct
in good skin
hygiene; e.g.,
wash
thoroughly, pat
dry carefully and
gently massage
with lotion or
appropriate
cream.
providing
opportunity
for timely
intervention.
2.
Maintaining
clean, dry
skin provides
a barrier to
infection.
Patting skin
dry instead of
rubbing
reduces skin
of dermal
trauma to
dry/fragile
skin.
Massaging
increases
wound lesion
healing.
at the wound
site with new
cells produced
by the
surrounding
tissue.
(Source:
Maternal and
Child Health
Nursing,
Pillitteri p. 582)
improve
condition.
3. Reposition
frequently.
4. Maintain
clean, dry,
wrinkle-free
linen, preferably
soft cotton
fabric.
circulation to
the skin and
promotes
comfort.
3. Reduces
stress on
pressure
points,
improves
blood flow to
tissues and
promotes
healing.
4. Skin
friction
caused by
movement
over
wet/wrinkled
5. Encourage
ambulation / out
of bed as
tolerated.
DEPENDENT:
6. Provide
foam / flotation /
alternate
pressure
mattress or bed.
or rough
sheets leads
to irritation of
fragile skin
and
increases risk
of infection.
5. Decreases
pressure on
skin from
prolonged
bedrest.
6. Reduces
pressure on
skin, tissue
and lesions.
7. Apply /
administer
topical /
systemic drugs
as indicated.
8. Refer to
physical therapy
for regular
exercise /
activity program.
7. Used in
treatment of
skin lesions.
Use of
agents such
as prederm
spray can
stimulate
circulation,
enhancing
healing
process.
8. Promotes
improved
muscle tone
and skin
health.
5. NURSING CARE PLAN FOR FEAR
CUES NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBJECTIVE INTERVENTION RATIONALE EVALUATION
Subjective:
Client verbalized:
“Takot ako
gumalaw kasi baka
bumuka ung tahi
ko”
Objective:
Patient has
avoidance to
move
Fear r/t
surgical
incision
Fear is an
emotion or
feeling of
apprehension
aroused by
impending or
seeming
danger, pain or
other perceived
threat. The fear
may be in
response to an
immediate or
LONG
TERM:
After nursing
intervention,
the client will
be able to
minimize her
fear.
SHORT
TERM:
INDEPENDENT:
1. Ask client’s
feeling about
her fear.
2. Encourage
contact with a
peer who has
successfully
dealt with a
similar situation.
1.
Expressing
client’s
feeling may
lessen her
fear and ease
her anxiety
2. Client is
more likely to
believe other
who have had
Client was
able to
minimize her
fear
Increased
respiratory
current threat,
or in response
to something
the person
believes will
happen
(Source:
Fundamentals
of Nursing
p1017)
After the
nursing
intervention
the client will
be able to
apply
intervention
intended to
improve
condition.
3. Discuss to
client proper
positioning,
transferring and
ambulation to
assure client
that her suture
will not open.
4. Assist client
in positioning,
transferring and
ambulation
similar
experience
3. Provides a
healthy outlet
for energy
generated by
feeling and
promotes
relaxation
6. NURSING CARE PLAN FOR RISK FOR INJURY
CUES NURSING
DIAGNOSI
S
SCIENTIFIC
EXPLANATIO
N
OBJECTIVE
S
INTERVENTION
S
RATIONALE EVALUATIO
N
NOTE:
Risk
diagnosis is
not
evidenced
by signs
and
symptoms,
as the
problem
has not
occurred
and nursing
intervention
s are
directed at
prevention.
Risk for
injury r/t
Post-
operative
condition
Risk for injury
is a state in
which the
individual is at
risk for injury
as a result of
environmental
conditions
interacting with
the individual’s
adaptive and
defense
resources.
(Source:
Fundamentals
of Nursing 7th
Edition, by
Kozier, page
673)
LONG
TERM:
After the
nursing
intervention
the client will
be able to
demonstrate
behaviors,
lifestyle
changes to
reduce risk
factors and
protect self
from injury.
SHORT
TERM:
INDEPENDENT
1. Assess mood,
coping abilities,
personal styles.
2. Ascertain
knowledge of
safety
needs/injury
prevention and
motivation.
3. Provide
information
regarding the
1. Some mood, coping
abilities and personal
styles might result in
carelessness/increase
d risk-taking without
consideration after the
consequences.
2. To prevent injury in
home, community and
work setting.
3. Providing, in a
simple and direct
manner, specific
factual information into
The client
was able to
demonstrate
behavior and
lifestyle
changes to
reduce risk
factors and
protect self
from injury.
After the
nursing
intervention
the client will
be able to
apply
interventions
intended to
improve
condition.
condition that
may result in
increased risk of
injury.
4. Discuss the
importance of
self-monitoring
condition/emotion
s that can
contribute to
occurrence of
injury.
DEPEDENT
5. Refer to the
resources as
indicated.
the client.
4. Discussion
encourages
participation by
learner.
5. A discharge note
and referral summary
are completed when
the client is being
discharged and
transferred to another
institution or to a home
setting where a visit by
a community health
nurse is required.
7. NURSING CARE PLAN FOR RISK FOR POSTOPERATIVE POSITIONING INJURY
CUES NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBJECTIVE INTERVENTION RATIONALE EVALUATION
NOTE:
A risk
diagnosis is
not evident by
signs and
symptoms, as
d problem has
not occurred
and nursing
intervention
are directed at
prevention
Risk for
Postoperative
Positioning
Injury
Surgery can
involve many
body systems
both directly
and indirectly
and is a
complex
experience for
the client.
Maintain
respiratory and
skeletal muscle
function to
prevent post
LONG TERM:
After nursing
intervention,
the client will
be able to be
free from any
untoward
injury.
SHORT
TERM:
INDEPENDENT:
1. Discuss the
length of
procedure and
customary
positioning
2. Provide
safety measures
♪ lock/cart bed
♪ maintain
body alignment
♪ protect body
1. To increase
awareness of
potential of
potential
complications
2. To maintain
position and
prevents client
from any injury
Client was able
to be free from
any untoward
injury
surgical
complications.
(Source:
Medical-
Surgical
Nursing
handbook p585)
After the
nursing
intervention
the client will
be able to
apply
interventions
intended to
improve
condition.
from contact
with metal parts
of the operating
room
♪ position
extremities to
facilitate
periodic
evaluation of
safety,
circulation,
nerve pressure
and body
alignment
♪ reposition
slowly and at
transfer and in
bed
3. Assist client
in changing
3. To prevent
bed sores and
promote skin
and tissue
positions and
transferring
integrity.
8. NURSING CARE PLAN FOR IMPAIRED BED MOBILITY
CUES NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
GOAL AND
OBJECTIVE
INTERVENTION RATIONALE EVALUATION
Subjective:
The client
verbalized “Medyo
nahihirapan akong
gumalaw kase nga
dahil sa tahi ko.”
“Kailangan dahan-
dahan lang kase
kapag napamali ng
galaw kumikirot
yong parte na may
tahi.”
Impaired
bed mobility
related to
pain
discomfort
The sensory
experience of
pain depends
on the
interaction
between the
nervous system
and the
environment.
The processing
of noxious
stimuli and the
resulting
LONG
TERM:
After the
nursing
intervention,
the client will
be able to
demonstrate
techniques /
behaviors
that enable
safe
INDEPENDENT:
1. Assist on / off
bedpan and into
sitting position
when possible.
2.
Demonstrate /
assist with
transfer
techniques and
use of mobility
1. Facilitates
elimination.
2. Facilitates
self-care and
client’s
independence.
Proper
transfer
techniques
The client was
able to
demonstrate
techniques /
behaviors that
enable safe
repositioning.
Objective:
impaired
ability: turn
side to side
perception of
pain involve the
peripheral and
central nervous
system.
(Source:
Medical-
Surgical
Nursing,
Brunner and
Suddarth p.
220)
repositioning.
SHORT
TERM:
After the
nursing
intervention,
the client will
be able to
apply the
interventions
intended to
improve
condition.
aids.
3. Encourage
continuation of
exercises.
DEPENDENT:
4. Provide
foam / flotation
mattress.
prevent
shearing
abrasions
dermal injury
related to
scooting.
3. To
maintain /
enhance gains
in strength /
muscle
control.
4. Reduces
pressure on
skin / tissues
that can impair
circulation,
potentiating
risk of tissue
ischemial
breakdown.
9. NURSING CARE PLAN FOR SELF-CARE DEFICIT
CUES NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBJECTIVE INTERVENTION RATIONALE EVALUATION
Subjective:
The patient
stated, “Eto
nga hindi ako
makaligo kasi
masakit…”
Objective:
Self-care
deficit related
to Post-
Operative
Incision
A self-care
deficit exists
when the self-
care agency is
not able to
meet some or
all the
components of
Therapeutic
Self-Care
LONG
TERM:
After the
nursing
intervention,
the patient
will be able to
perform self-
care activities
within level of
INDEPENDENT:
1. Provide
privacy during
personal care
activities.
2. Inspect skin
1. Privacy
enables a client
to participate
without worrying
about later
embarrassment.
2. Presence of
such lesions may
The patient
has able to
perform self-
care activities
with in level of
own ability.
Able to
change
her
clothes
but
unable
to take
a bath.
Demand. own ability.
SHORT
TERM:
After the
nursing
intervention,
the client will
be able to
apply the
interventions
intended to
improve
condition.
regularly
3. Encourage
scheduling
activity early in
the day or during
the time when
energy level is
test.
4. Avoid doing
things for client
that client can do
for self,
providing
require treatment
as well as signal
the need for
closer monitoring
/ protective
intervention.
3. Clients with
MS expand a
great deal of
energy to
complete ADL’s,
increase the risk
of fatigue, with
often progresses
through the day.
4. These clients
may become
fearful and
dependent and
assistance as
necessary.
5. Encourage
client to perform
self-care to the
maximum of
ability as defined
by client. Do not
rush client.
although
assistance is
helpful in
preventing
frustration it is
important for
client to do as
much as possible
for self to
maintain self-
esteem and
promote
recovery.
5. Promotes
independence
and sense of
control, may
decrease
feelings of
helplessness.
10. NURSING CARE PLAN FOR DECISIONAL CONFLICT
CUES NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBJECTIVE INTERVENTION RATIONALE EVALUATION
Subjective:
The client
verbalized,
“Noong una,
hindi dito ang
plano kong
manganak.”
Objective:
The
client
has
delayed
Decisional
Conflict r/t
lack of
relevant
information.
Uncertainty
about course of
action to be
taken when
choice among
competing
actions involves
risk, loss or
challenged to
personal life
values.
(SourceNANDA)
LONG TERM:
After the
nursing
intervention,
the patient will
be able to
decide to
which
institution she
will give birth.
SHORT
TERM:
INDEPENDENT:
1. Encourage
verbalization of
conflict.
2. Determine
current
knowledge.
1. Lack of
information
can interfere
client’s
response to
illness
situation.
2. Provides
clues to assist
client to
develop
coping and
The patient
able to decide
to which
institution she
gave birth.
decision
-making. After the
nursing
intervention,
the client will
be able to
apply the
interventions
intended to
improve
condition.
3. Correct
misperceptions
client may have
and provide
information.
4. Encourage
involvement of
family as
desired.
DEPENDENT:
5. Refer to other
resource as
necessary.
regain
equilibrium.
3. Provides for
better
decision-
making.
4. Assist in
identification
and correction
of perception
of reality and
enables
problem
solving to
begin.
5. To provide
support for the
client.
Additional
assistance
may be
needed to
help client
resolve
making
decisions.
11. NURSING CARE PLAN FOR INEFFECTIVE BREASTFEEDING
CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective:
The client
verbalized,
“Ayokong
magpabreastfeed.”
Objective:
Ineffective
Breastfeeding
r/t Knowledge
Deficit.
Dissatisfaction
or difficulty a
mother, infant
or child
experiences
with the
breastfeeding
process.
LONG TERM:
After the
nursing
intervention,
the client will
be able to
have effective
breastfeeding.
SHORT
TERM:
After the
nursing
intervention,
the client will
be able to
apply the
intervention
INDEPENDENT:
1. Assess client
knowledge
about
breastfeeding
and extent of
instruction that
has been given.
2. Encourage
discussion of
current
breastfeeding
experience.
3. Determine
maternal
1. Maybe for
some reasons
that the client
misinterpreted
the
instruction.
2. To assess
furthermore.
3. Maybe she
is in the stage
of “Taking- in
The client
assumes
responsibility
for effective
breastfeeding.
intended to
improve
condition.
feelings.
4. Give
emotional
support to
mother. Use 1:1
instruction with
each feeding
during hospital
stay/ client visit.
5. Promote early
management of
breastfeeding
problems.
6. Encourage
spouse
education and
Phase”.
4. Because
some mothers
wanted to
have an
attention due
to their
condition.
5. So that we
can assure
the main
problem of
the client.
support when
appropriate.
6. For
emotional
support to the
mother or the
client.
12. NURSING CARE PLAN FOR RISK FOR INFECTION
CUES
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIO
N
OBJECTIVES INTERVENTION RATIONALE EVALUATION
NOTE:
Risk diagnosis
is not
evidenced by
signs and
symptoms, as
the problem
has not
Risk for
infection
related to
surgical
incision
A wound can
be infected
with
microorganism
s at the time of
injury, during
surgery, or
postoperatively
LONG TERM:
After the
nursing
intervention,
the patient will
be able to
prevent or
reduce risk of
INDEPENDENT:
1. Observe for
localized signs of
infection at
insertion sites of
invasive lines,
sutures, surgical
incisions or
1. Provides
information
about the
severity and
presence of
infection.
The patient’s
risk for
infection has
been
prevented.
occurred and
nursing
interventions
are directed at
prevention.
. Surgical
infection is
most likely to
become
apparent 2 to
11 days
postoperatively
.
Contamination
of a wound
surface with
microorganism
s (colonization)
is an inevitable
result. Because
the colonizing
organisms
compete with
new cells for
oxygen and
infection.
SHORT TERM:
After the
nursing
intervention the
client will be
able to apply
interventions
intended to
improve
condition.
wounds.
2. Practice/
instruct in Good
Handwashing
and aseptic
wound care.
3. Monitor the
vital signs. Note:
onset of fever,
chills,
diaphoresis,
reports of
increase
abdominal pain.
4. Cleanse
incisions or
insertion sites
2. Reduces
risk of
spread of
pathogens
3. Provides
information
about the
developing
sepsis and
abscess.
4. Prevents
introduction
of pathogens
nutrition, and
because their
by-products
can interfere
with a healthy
surface
condition, the
presence of
contamination
can impair
wound healing
and lead to
infection.
(Source:
Fundamentals
of nursing,
page 861,
Kozier)
daily and prn with
povidoneiodine or
other appropriate
solution.
5. Instruct client
or SO(s) in
techniques to
protect the
integrity of skin,
care for lesions,
and prevention of
spread of
infection.
6. Instruct the
patient in wound
healing.
7. Promote quiet
and restful
into the body
5. Prevents
introduction
of pathogens
into the body
6. To assess
the healing
process
7. To regain
energy for
faster
recovery
environment
conducive for rest
and sleep.
8. Provide
nutritious food.
DEPENDENT:
9. Administer
medication
regimen
(antibiotic) and
note the client’s
response to
determine
effectiveness of
therapy or
presence of side
8. To regain
energy for
faster
recovery
effects.
13. NURSING CARE PLAN FOR FLUID VOLUME EXCESS
CUES NURSING
DIAGNOSI
S
SCIENTIFIC
EXPLANATIO
N
OBJECTIVE
S
INTERVENTIONS RATIONALE EVALUATIO
N
Subjective:
The client
verbalized,
“Minamanas
ako.”
Fluid
volume
excess r/t
Pregnancy
Fluid volume
excess occurs
when the body
retains both
water and
sodium in
similar
proportions to
LONG
TERM:
After the
nursing
intervention
the client will
be able to
INDEPENDENT:
1. Measure I & O
noting positive
balance (intake in
excess of output).
Weigh daily, and
note gain more
1. Reflects
circulating volume
status,
developing/resoluti
on of fluid shifts,
and response to
After the
nursing
intervention
the client
was able to
demonstrate
fluid volume
Objective:
Edema
Measurement:
normal ECF.
This is
commonly
referred to as
hypervolemia
(increased
blood volume).
FVE is always
secondary to
an increase in
the total
sodium
content. In
FVE, both
intravascular
and interstitial
spaces have
an increased
water and
sodium
content.
demonstrate
fluid volume
balance, with
balanced I &
O, stable
weight, VS
within the
client’s
normal range
and absence
of edema.
SHORT
TERM:
After the
nursing
intervention
the client will
be able to
apply the
than 0.5 kg/day.
2. Monitor BP. Note
external jugular and
abdominal vein
distention.
3. Assess the
respiratory status,
noting increased
therapy. Positive
fluid balance/weight
gain often reflects
continuing fluid
retention.
2. BP elevations
are usually
associated with
fluid volume excess
but may not occur
because of fluid
shifts of the
vascular space.
Distention of
external jugular
vein in associated
with vascular
congestion/edema.
3. Indicative of
balance.
Excess
interstitial fluid
is known as
edema.
(Source:
Fundamentals
of Nursing 7th
Edition, by
Kozier, page
1363)
interventions
intended to
improve
condition.
respiratory rate,
dyspnea.
4. Auscultate lung,
noting
diminished/absent
breath sounds and
developing
adventitious
sounds.
5. Monitor for
cardiac
dysrhythmias.
Auscultate heart
sounds, noting
development of
signs and
pulmonary
congestion/edema.
4. Increasing
pulmonary
congestion may
result in the
consolidation,
impaired gas
exchange, and
complications, e.g.
pulmonary edema.
5. May be caused
by heart failure,
decreased
coronary arterial
perfusion, or
electrolyte
symptoms (gallop
rhythm).
6. Assess degree
of
peripheral/depende
nt edema.
7. Measure
abdominal girth.
8. Provide frequent
imbalance.
6. Fluid shift into
tissues as a result
of sodium and
water retention,
decreased albumin,
and increased
antidiuretic
hormone (ADH).
7. Reflects
accumulation of
fluids (ascites)
resulting from loss
of plasma
proteins/fluid into
the peritoneal
mouth care;
occasional ice
chips, schedule
fluid intake round
the clock.
DEPENDENT:
9. Monitor serum
albumin and
electrolytes.
space.
8. Decreased
sensation of thirst
especially when
fluid intake is
restricted.
9. Decreased
serum albumin
affects the plasma
colloid osmotic
pressure resulting
in edema
formation. Reduced
renal blood flow
accompanied by
elevated ADH and
10. Monitor serial
chest x-rays.
11. Restrict sodium
and fluids as
indicated.
aldosterone levels
and the use of
diuretics may
cause various
electrolyte
shifts/imbalances.
10. Vascular
congestion,
pulmonary edema,
and pleural
effusions frequently
occur.
11. Sodium may be
restricted to
minimize fluid
retention
extravascular
sources. Fluid
restriction may be
—
12. Administer salt-
free
albumin/plasma
expanders as
indicated.
13. Administer
medications as
indicated:
necessary to
correct/prevent
dilutional
hyponatremia.
12. Albumin may
be used to increase
the colloid osmotic
pressure in the
vascular
compartment,
thereby increasing
effective circulating
volume and
decreasing
formation of
ascites.
13. Used with
caution to control
edema and ascites,
DIURECTICS
POTASSIUM
POSITIVE
INOTROPIC
DRUGS and
ARTERIAL
VASODILATORS
block effect of
aldosterone, and
increase water
secretion while
sparing potassium
when conservative
therapy with bed
rest and sodium
restriction does not
alleviate problem.
Diuretic given with
coordination with
albumin
administration may
enhance fluid
removal. Serum
and cellular
potassium are
usually depleted
because of liver
disease and urinary
losses. Given to
increase cardiac
output/improve
renal blood flow
and function,
thereby ±reducing
excess fluid.
14. NURSING CARE PLAN FOR FATIGUE
CUES NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBJECTIVE INTERVENTION RATIONALE EVALUATION
Subjective:
The client
verbalized, “Tulog
lang ako ng tulog
kasi pakiramdam
Fatigue
related to
stress
It is though that
a person who is
moderately
fatigued usually
has a restful
sleep. Fatigue
LONG
TERM:
After the
nursing
intervention,
the patient
INDEPENDENT:
1. Discuss
lifestyle changes
or limitations
imposed by
1. Discussion
encourages
participation by
learner and
permits
The patient
has improved
sense of
energy.
ko lagi akong
pagod na pagod…”
Objective:
Lethargic
and Drowsy
also affects a
person’s sleep
pattern. The
more tired the
person is the
shorter the first
period of
paradoxical
(REM) sleep.
As the person
rests, the REM
periods become
longer.
(Source:
Fundamentals
of Nursing,
page 1118, by
Kozier)
will be able
to improved
sense of
energy.
SHORT
TERM:
After the
nursing
intervention
the client will
be able to
apply the
interventions
intended to
improve
condition.
fatigue.
2. Encourage
client to do
whatever
possible. (e.g.
self-care, sit-up
in chair, walk).
Increase activity
level as
tolerated.
3. Instruct in
methods to
conserve
energy.
reinforcement.
And repetition at
learner’s level.
2. Enhances
strength/stamina
and enables
client to become
more active
without undue
fatigue.
3. To lessen
fatigue
4. Weakness
4. Assist with
self-care needs;
keep bed in low
position and
travel ways
clear of
furniture, assist
with ambulation
as indicated.
5. Provide
environment
conducive to
relief of fatigue.
Temperature
and level of
humidity are
known to affect
exhaustion.
may make
ADL’s different
to complete or
place the client
at risk for injury
during activity.
5. To lessen the
occurrence of
fatigue.
6. Prevent
dehydration
which increases
fatigue.
6. Encourage
adequate fluid
intake.