NURSING CARE PLAN

Name of Patient: X Medical Diagnosis: Chronic renal failure secondary to DM nephropathy.

Nursing Diagnosis: Risk for ineffective protection related to abnormal blood profile.

Findings Expected Outcome Nursing Interventions and Rationale Actual Evaluation

O= Received patient on bed,
awake, conscious with
intravenous fluid of # 1 D5
0.3% NaCl 500cc @ KVO,
infusing well at left arm.
> With ventriculostomy tube
freely draining to blood bag;
dressing is dry and intact.
> With traeostomy attached
to mechanical ventilator,
with FIO2 of 80%.
> With nasogastric tube for
feeding.
WBC= 20T
RBC= 3.5 million/uL
> With the following vital
signs of:
>T=36.5oC.
>P=100bpm.
>R= 22 cpm.
>BP=130/80mmhg
Within 8 hours of nursing
intervention, the patient will
be able to:
1. Experience no signs/
symptoms of bleeding.
2. Maintain / demonstrate
improvement in laboratory
values.
-Hand washing and observe proper medical asepsis and limit visitors. After 7-8 hours of nursing
R= to limit transmission of infections since the patient has a weak intervention, the patient was:
immune system.
1. Still in coma, no signs of
-Note reports of increasing fatigue, weakness. Observe for tachycardia, increased ICP noted.
pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient
activities to avoid fatigue. 2. Displayed no further
R=May reflect effects of anemia and cardiac response. To let the patient deterioration.
rest.
3. With stable vital signs of
-Note for the sign of infections in the operative site and change the >T=36.8oC.
dressing regularly. >P= 101 bpm.
R= since the patient undergone ventriculostomy, noting and changing the >R= 21 cpm.
dressing can help minimize the infection. >BP=140/80mmhg

Noted By:

Senior/ Staff Nurse & Nurse Supervisor

 NURSING CARE PLAN

Name of Patient: X Medical Diagnosis: Acute Myocardial Infarction

Nursing Diagnosis: Infective Tissue Perfusion related to Poor Myocardial Contractility

Findings Expected Outcome Nursing Interventions and Rationale Actual Evaluation

O= Received patient on bed,
awake, conscious with
intravenous fluid of # 1 D5
0.3% NaCl 500cc @ KVO,
infusing well at left arm.
> With ventriculostomy tube
freely draining to blood bag;
dressing is dry and intact.
> With traeostomy attached
to mechanical ventilator,
with FIO2 of 80%.
> With nasogastric tube for
feeding.
WBC= 20T
RBC= 3.5 million/uL
> With the following vital
signs of:
>T=36.5oC.
>P=100bpm.
>R= 22 cpm.
>BP=130/80mmhg
Within 8 hours of nursing
intervention, the patient will
be able to:
1. Experience no signs/
symptoms of bleeding.
2. Maintain / demonstrate
improvement in laboratory
values.
-Hand washing and observe proper medical asepsis and limit visitors. After 7-8 hours of nursing
R= to limit transmission of infections since the patient has a weak intervention, the patient was:
immune system.
1. Still in coma, no signs of
-Note reports of increasing fatigue, weakness. Observe for tachycardia, increased ICP noted.
pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient
activities to avoid fatigue. 2. Displayed no further
R=May reflect effects of anemia and cardiac response. To let the patient deterioration.
rest.
3. With stable vital signs of
-Note for the sign of infections in the operative site and change the >T=36.8oC.
dressing regularly. >P= 101 bpm.
R= since the patient undergone ventriculostomy, noting and changing the >R= 21 cpm.
dressing can help minimize the infection. >BP=140/80mmhg

Noted By:

Senior/ Staff Nurse & Nurse Supervisor


Name of Patient: X
Nursing Diagnosis: Infective Tissue Perfusion related to Poor Myocardial Contractility
Findings
O= Received patient on bed,
awake, conscious with
intravenous fluid of # 1 D5
0.3% NaCl 500cc @ KVO,
infusing well at left arm.
> With ventriculostomy tube
freely draining to blood bag;
dressing is dry and intact.
> With traeostomy attached
to mechanical ventilator,
with FIO2 of 80%.
> With nasogastric tube for
feeding.
WBC= 20T
RBC= 3.5 million/uL
> With the following vital
signs of:
>T=36.5oC.
>P=100bpm.
>R= 22 cpm.
>BP=130/80mmhg
Noted By:
Senior/ Staff Nurse
Medical Diagnosis:
Expected Outcome
Within 8 hours of nursing
intervention, the patient will
be able to:
1. Experience no signs/
symptoms of bleeding.
2. Maintain / demonstrate
improvement in laboratory
values.
& Nurse Supervisor
NURSING CARE PLAN
Nursing Interventions and Rationale Actual Evaluation
-Hand washing and observe proper medical asepsis and limit visitors. After 7-8 hours of nursing
R= to limit transmission of infections since the patient has a weak intervention, the patient was:
immune system.
1. Still in coma, no signs of
-Note reports of increasing fatigue, weakness. Observe for tachycardia, increased ICP noted.
pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient
activities to avoid fatigue. 2. Displayed no further
R=May reflect effects of anemia and cardiac response. To let the patient deterioration.
rest.
3. With stable vital signs of
-Note for the sign of infections in the operative site and change the >T=36.8oC.
dressing regularly. >P= 101 bpm.
R= since the patient undergone ventriculostomy, noting and changing the >R= 21 cpm.
dressing can help minimize the infection. >BP=140/80mmhg

Name of Patient: X
Nursing Diagnosis: Infective Tissue Perfusion related to Poor Myocardial Contractility
Findings
O= Received patient on bed,
awake, conscious with
intravenous fluid of # 1 D5
0.3% NaCl 500cc @ KVO,
infusing well at left arm.
> With ventriculostomy tube
freely draining to blood bag;
dressing is dry and intact.
> With traeostomy attached
to mechanical ventilator,
with FIO2 of 80%.
> With nasogastric tube for
feeding.
WBC= 20T
RBC= 3.5 million/uL
> With the following vital
signs of:
>T=36.5oC.
>P=100bpm.
>R= 22 cpm.
>BP=130/80mmhg
Noted By:
Senior/ Staff Nurse
Medical Diagnosis:
Expected Outcome
Within 8 hours of nursing
intervention, the patient will
be able to:
1. Experience no signs/
symptoms of bleeding.
2. Maintain / demonstrate
improvement in laboratory
values.
& Nurse Supervisor
NURSING CARE PLAN
Nursing Interventions and Rationale Actual Evaluation
-Hand washing and observe proper medical asepsis and limit visitors. After 7-8 hours of nursing
R= to limit transmission of infections since the patient has a weak intervention, the patient was:
immune system.
1. Still in coma, no signs of
-Note reports of increasing fatigue, weakness. Observe for tachycardia, increased ICP noted.
pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient
activities to avoid fatigue. 2. Displayed no further
R=May reflect effects of anemia and cardiac response. To let the patient deterioration.
rest.
3. With stable vital signs of
-Note for the sign of infections in the operative site and change the >T=36.8oC.
dressing regularly. >P= 101 bpm.
R= since the patient undergone ventriculostomy, noting and changing the >R= 21 cpm.
dressing can help minimize the infection. >BP=140/80mmhg

Name of Patient: X
Nursing Diagnosis: Infective Tissue Perfusion related to Poor Myocardial Contractility
Findings
O= Received patient on bed,
awake, conscious with
intravenous fluid of # 1 D5
0.3% NaCl 500cc @ KVO,
infusing well at left arm.
> With ventriculostomy tube
freely draining to blood bag;
dressing is dry and intact.
> With traeostomy attached
to mechanical ventilator,
with FIO2 of 80%.
> With nasogastric tube for
feeding.
WBC= 20T
RBC= 3.5 million/uL
> With the following vital
signs of:
>T=36.5oC.
>P=100bpm.
>R= 22 cpm.
>BP=130/80mmhg
Noted By:
Senior/ Staff Nurse
Medical Diagnosis:
Expected Outcome
Within 8 hours of nursing
intervention, the patient will
be able to:
1. Experience no signs/
symptoms of bleeding.
2. Maintain / demonstrate
improvement in laboratory
values.
& Nurse Supervisor
NURSING CARE PLAN
Nursing Interventions and Rationale Actual Evaluation
-Hand washing and observe proper medical asepsis and limit visitors. After 7-8 hours of nursing
R= to limit transmission of infections since the patient has a weak intervention, the patient was:
immune system.
1. Still in coma, no signs of
-Note reports of increasing fatigue, weakness. Observe for tachycardia, increased ICP noted.
pallor of skin/ mucous membranes, dyspnea , and chest pain. Plan patient
activities to avoid fatigue. 2. Displayed no further
R=May reflect effects of anemia and cardiac response. To let the patient deterioration.
rest.
3. With stable vital signs of
-Note for the sign of infections in the operative site and change the >T=36.8oC.
dressing regularly. >P= 101 bpm.
R= since the patient undergone ventriculostomy, noting and changing the >R= 21 cpm.
dressing can help minimize the infection. >BP=140/80mmhg