4 - NCP

NURSING CARE
PLANS
IDEAL
NURSING CARE
PLANS
1st Priority
Name: Cardo Dalisay

Admitting Physician: Dr. Onyok
Nursing Diagnosis: Ineffective breathing pattern related to hypoxia
Reference: Doenges, M.E., Moorhouse, M. F. and Murr, A. C. (2012). Nursing Care Plans, Guidelines for Individualizing Client Care
Across the Life Span. 14th ed. P. 328. F. A. Davis Company; Pennsylvania.
Assessment Objectives Interventions Rationale

Subjective: Short term goal: Independent:
The patient verbalizes At the end of 2 hours of nursing 1. Assess and record respiratory rate The average rate of
Shortness of breathing. intervention the patient will be able and depth at least every 4 hours. respiration for adults is 10 to
to: 20 breaths per minute. It is
important to take action
Demonstrate proper breathing
when there is an alteration in
exercise
the pattern of breathing to
Verbalized understanding about
detect early signs of
the importance to keep rested to
respiratory compromise.
prevent dyspnea
2. Assess ABG levels, according to This monitors oxygenation
facility policy. and ventilation status.
3. Observe for breathing patterns Unusual breathing patterns
Objective: may imply an underlying
disease process or
Altered chest excursion Long term goal
dysfunction. Cheyne-Stokes
Apnea At the end of 16 hours of nursing respiration signifies bilateral
Assumption of three-point intervention the patient will be able dysfunction in the deep
position to breathe to: cerebral
(bending forward while or diencephalon related
Maintained an effective breathing
supporting self by placing with brain injury or metabolic
pattern as evidenced by relaxed
one hand on each knee) abnormalities. Apneusis and
breathing at stable respiratory
Changes in respiratory ataxic breathing are related
rate and minimal or no
rate and depth with failure of the respiratory
complaints of dyspnea
Cough centers in the pons and
Verbalized feeling comfortable
Cyanosis medulla.
when beathing
Decreased Po2 and Sao2;
4. Auscultate breath sounds at least This is to detect decreased or
increased Pco2 adventitious breath sounds
every 4 hours.
Dyspnea Work of breathing increases
5. Assess for use of accessory muscle.
Fremitus greatly as lung compliance
Holding breath decreases.
Increased anteroposterior 6. Monitor for diaphragm- Paradoxical movement of the
chest diameter Matic muscle abdomen (an inward versus
Increased restlessness, outward movement during
apprehension, and inspiration) is indicative of
metabolic rate fatigue or weakness respiratory muscle fatigue an
Increased work of d weakness.
(paradoxical motion)
breathing, use of
accessory muscles 7. Observe for retractions or flaring These signs signify an
Nasal flaring of nostrils. increase in respiratory effort.
Noisy respirations
Pursed-lip breathing or Collaborative:
prolonged expiratory
phase 8. Utilize pulse oximetry to check Pulse oximetry is a helpful
oxygen saturation and pulse rate, tool to detect alterations in
Reduced VC/total lung
as ordered oxygenation initially; but, for
volume
Reduced vital capacity CO2 levels, end tidal CO2
Respiratory depth monitoring or
changes arterial blood gases (ABGs)

would require being obtained.
Tachypnea/bradypnea or
These techniques promote
cessation of respirations 9. Encourage sustained deep breaths
deep inspiration, which
when off the ventilator by:
increases oxygenation and
Use of accessory muscles Using demonstration: highlighting
prevents atelectasis.
slow inhalation, holding end
Controlled breathing methods
inspiration for a few seconds, and
may also aid slow
passive exhalation
respirations in patients who
Utilizing incentive spirometer are tachypneic.
Requiring the patient to yawn Prolonged expiration prevents
air trapping.
10. Teach the patient with the These measures allow patient
significant others about: to participate in maintaining
pursed-lip breathing health status and improve
abdominal breathing ventilation.
performing relaxation techniques

performing relaxation techniques
taking prescribed medications
(ensuring accuracy of dose and
frequency and monitoring adverse
effects)
scheduling activities to
avoid fatigue and provide for rest
periods
This information promotes
11. Educate patient about
safe and effective medication
medications: indications, dosage,
administration
frequency, and possible side effects.
Incorporate review of metered-dose
inhaler and nebulizer treatments,
as needed. Extra activity can worsen
12. Encourage frequent rest periods shortness of breath. Ensure
and teach patient with the the patient rests between
significant others to pace activity. strenuous activities.
2nd Priority
Name: Cardo Dalisay

Nursing Diagnosis: Imbalance Nutrition Less than body requirements related to unwillingness to eat

1. Note real, exact weight; do not These anthropomorphic
The patient verbalizes At the end of 2 hours of nursing
estimate. assessments are vital that
weight loss or loss of appetite. intervention the patient will be able
they need to be accurate.
to:
These will be used as basis
Verbalize proper selection of for caloric and nutrient
foods or meals that will achieve a requirements.
cessation of weight loss.
2. Look for physical signs of poor
The patient encountering
nutritional intake.
nutritional deficiencies may
resemble to be sluggish and
fatigued. Other
manifestations include
Objective: Long term goal: decreased attention span,
Allergies confused, pale and dry skin
Within the end of 16 hours of
Anorexia subcutaneous tissue loss,
nursing intervention the patient will
Depression dull and brittle hair, and
be able to:
Nausea and vomiting red, swollen tongue and
Actual or potential Eat one whole share of meal with mucous membranes. Vital
metabolic needs in excess good appetite. signs may show tachycardia
of intake with weight loss Have a weight within the ideal and elevated BP.
Diarrhea and/or body weight. Paresthesias may also be
steatorrhea present.
Excessive hair loss

Hyperactive bowel sounds The Food Guide Pyramid
3. Link usual food intake to USDA
Loss of subcutaneous emphasizes the importance
Food Pyramid, noting slighted or
tissue of balanced
omitted food groups.
Pale, dry skin eating. Omission of entire
Poor muscle tone food groups increases risk of
Red, swollen oral mucous deficiencies.
membranes
food intake less than the
recommended daily 4. Note the patients perspective and Various psychological,
feeling toward eating and food. psychosocial, religious, and

allowance (RDA) with or
cultural factors determine
without weight loss the type, amount, and
Weight 10% to 20% below appropriateness of food
ideal body weight and utilized.
height
5. Ascertain etiological factors for Several factors may affect

decreased nutritional intake. the patients nutritional
intake, so it is vital to assess
properly. Patients with
dentition problems
need referral to a dentist,
whereas patients with
memory losses may need
service like Meals on
Wheels. Other medications
also have an effect on the
appetite of the patient
6. Encourage the patient to recall the

Determination of type,
food intake and recorded it.
amount, and pattern of food
or fluid intake is facilitated
by accurate documentation
by the patient or caregiver
as the intake occurs.
Depending on the etiological
7. Establish appropriate short and factors of the problem,
long term goal movement in nutritional
status may take a long time.
This is to promote comfort

8. Suggests ways to assist the patient to the patient in the meal
with meals, as needed. Ensure a time and increase its urge to
pleasant environment, facilitate eat. Proper oral hygiene is to
proper position, and provide good prevent tooth decay which
oral hygiene and dentition. could lead to low of appetite.
Collaborative:
Family members may

9. Take a nutritional history with the
provide more accurate
participation of significant others.
details on the patients
eating habits, especially if
patient has altered
perception.
10. Review laboratory values that Laboratory tests play a
indicate well-being or significant part in
deterioration. determining the patients
nutritional status. An
abnormal value in a single
diagnostic study may have
many possible causes.
11. Ascertain healthy Experts like a dietician can

body weight for age and height. determine nitrogen balance
Refer to a dietitian for complete as a measure of the
nutrition assessment and methods nutritional status of the
for nutritional support. patient. A negative nitrogen
balance may mean protein
malnutrition. The dietician
can also determine the
patients daily requirements
of specific nutrients to
promote sufficient
nutritional intake.
12. Encourage exercise. Metabolism and utilization

of nutrients are improved by
activity.
13. Consult dietician for further Dieticians have a greater

assessment and recommendation understanding of the
regarding food preferences. nutritional value of foods
and may be helpful in
assessing specific ethnic or
cultural foods
3rd Priority
Name: Cardo Dalisay

Nursing Diagnosis: Acute pain related to pain from Congestive heart failure

Assess pain characteristics: Assessment of the pain
Patients verbalized pain At the end of 30 minutes of
Quality experience is the first step in
nursing intervention the patient will
Severity planning pain management
be able to demonstrate Pain relief
Location strategies.
measures
Onset
Such as Guided Imagery, breathing Duration
exercises, etc. Precipitating or relieving factors
Observe and monitored signs and Some people deny the
symptoms associated with pain, experience if pain when it is
such as BP, heart rate, present. Attention to

associated signs may help
Objective: Long term goal: temperature, color and moisture of the nurse in evaluating
Guarding behavior, skin, restlessness, and ability to pain.
protecting body part focus
Self-focused At the end of 1 hour of nursing
Narrowed focus intervention the patient will be able Assess for probable cause of pain Different etiological factors
Facial mask of pain to verbalize adequate relief of pain respond better to different
Alteration in muscle tone: or ability to cope with incompletely therapies

Provide rest periods to facilitate
listlessness or flaccidness; relieved of pain. The patients experience of
comfort, sleep, and relaxation
rigidity o tension pain may become
Autonomic response exaggerated as the result of

fatigue.
Some patients may be
Assess the patients expectations for
content to have pain
pain relief.
decreased; others will expect
complete elimination of
pain. This affects their
perceptions of the
effectiveness of the
treatment modality and
their willingness to
participate
Collaborative:
Determine the appropriate pain

NSAIDS work in peripheral
relief method
tissues. Some block
1. NSAIDS
synthesis of prostaglandins,
which stimulate nociceptors.
They are effective in
managing mild to moderate
pain
2. Opioid analgesics
Opioids may be
administered orally,
intravenously, systemically
by PCA systems or
epidurally (either by bolus
or continuous infusion).
Opioids are indicated for
severe pain, especially in the
hospice or home setting.
3. Local anesthetic agents Local anesthetics block pain
transmission and are used
for pain in specific areas of
Nonpharmacological methods
nerve distribution.
include the following:
1. Cognitive Behavioral strategies
The use of a mental picture
as follows:
or an imagined event
Imagery involves use of the five
Distraction techniques senses to distract oneself
Relaxation exercises, breathing from painful stimuli
execises, music theraphy.
2. Cutaneous Stimulation as Massage decreases muscle
follows tension and can promote
Massage of affected area when comfort
appropriate
Gave analgesics as ordered,

Pain medications are
evaluating effectiveness and
absorbed and metabolized
observing for any signs and
differently by patients, so
symptoms of untoward effects.
their effectiveness must be
evaluated individually by the
patient.
4th Priority
Name: Cardo Dalisay

Nursing Diagnosis: Activity Intolerance

Subjective: Short term: Dependent:
1. Evaluate clients actual and
Provides comparative
perceived limitations or degree
Verbal report of At the end of the 8-hour shift, the baseline and information
of deficit in light of usual
fatigue/weakness client will be able to identify negative about needed intervention.
status.
Exertional factors affecting activity intolerance, Symptoms may be
2. Note client reports of
discomfort/dyspnea use identified techniques to enhance contributing to intolerance
weakness, fatigue, pain and
activity intolerance and report of activity.
difficulty accomplishing tasks.
measurable increase in inactivity To determine current
3. Ascertain ability to stand and
intolerance. status and needs
move about and degree of
Objective: Long Term: assistance necessary of associated with
equipment. participation in desired
activities.
Abnormal heart At the end of the 16-hour shift,
4. Adjust activities. To prevent overexertion.
rate/blood pressure in the client will be able to demonstrate
5. Plan care to carefully balance To reduce fatigue.
response to activity a decrease in physiological signs of
rest periods with activities.
Electrocardiographic intolerance.
6. Promote comfort measures To enhance ability to
changes reflecting
and provide for relief of pain. participate in activities.
arrhythmias
7. Assist client in learning and To prevent injuries.
Functional Level
demonstrating appropriate
Classification
safety measures.
To enhance sense of well-
8. Encourage client to maintain
being.
positive attitude; suggest use
of relaxation techniques.
Independent:
1. Provide or monitor
medications and changes in For therapeutic aid when
treatment regimen. needed.
5th Priority
Name: Cardo Dalisay

Nursing Diagnosis: Ineffective Tissue Perfusion
Figure 34
1. Note customary baseline
Provides comparison with
data.
Verbal report of chest At the end of the 8-hour shift, the current findings.
2. Note mentation.
pain, dyspnea, nausea, client will be able to verbalize May be altered by
abdominal pain. understanding of condition, therapy increased BUN/Cr.
regimen and when to contact healthcare 3. Review results of To determine
provider. diagnostic studies. location/severity of
Objective:
4. Monitor for condition.
temperature, especially May indicate ischemic
Oliguria in presence of bright red colitis.
Anuria stool.
Hematuria 5. Measure circumference Useful in identifying
Restlessness of extremities, as edema in involved
Dysphagia indicated. extremity.
Arrhythmias 6. Elevate HOB and To promote
Use of accessory muscles maintain head in circulation/venous
Altered mental status midline or neutral drainage.
Hypoactive bowel sounds position.
Altered skin characteristic 7. Encourage quiet, restful Conserves energy.

atmosphere.
Altered sensations
Edema
8. Encourage rest after
Delayed healing
meals. To maximize blood flow to
9. Encourage early stomach.
ambulation, when Enhances venous return.
possible.
Long Term: 10. Apply ice and To reduce edema.
elevate limbs.
11. Encourage
At the end of the 16-hour, the client Smoking causes
smoking cessation.
will be able to demonstrate vasoconstriction.
behaviors/lifestyle changes to improve
circulation and demonstrate increased
perfusion as individually appropriate. Independent:
May be used to decrease

1. Administer medications
edema. Drugs used to
with caution.
improve tissue perfusion
also carry risk of adverse
2. Assist with treatment of responses.
underlying conditions. To improve organ function.
6th Priority
Name: Cardo Dalisay

Nursing Diagnosis: Excess Fluid Volume

1. Auscultate breath sounds
For presence of
Verbal report At the end of the 8-hour shift, the crackles/congestion.
of orthopnea client will be able to verbalize 2. Measure abdominal girth. For changes that may
and anxiety understanding of individual dietary/fluid indicate increasing fluid
restrictions. retention.
3. Evaluate mentation.
For confusion or personality
Objective:
changes.
4. Elevate edematous extremities,
To reduce tissue pressure
change position frequently.
Edema and risk of skin breakdown.
5. Place in semi-fowlers position,
Oliguria To facilitate respiratory effort.
as appropriate.
Adventitious Long Term: 6. Suggest interventions, such as To reduce discomfort of fluid
breath sounds oral care. restrictions.
Change in
At the end of the 16-hour, the client
mental status; Independent:
will be able to stabilize fluid volume as
restlessness
evidenced by balanced I/O, vital signs
1. Administer medications with May be used to decrease
within clients normal limits and free of
caution. edema.
signs of edema and demonstrate
2. Assist with procedures, as To aid for clients needs.
behaviors to monitor fluid status and
indicated.
reduce recurrence of fluid excess.
7th Priority
Name: Cardo Dalisay

Nursing Diagnosis: Risk for infection related to surgery.
Figure 36.
Subjective: Short term: Independent:
These affects the clients

Not applicable After the 12-hour shift, clients Assess for the presence
infection status, worsen
mother will be able to verbalize of underlying disease,
or demands time for
understanding of the causative lifestyle, nutritional
healing.
factor and identify interventions to status, skin trauma and
It could be signs of
prevent or reduce risk of infection. environmental exposure.
developing localized
Observe for changes in
infection.
Objective: Long term: skin color and warmth at
A first-line defence
the colostomy.
against healthcare-
Opening in the abdomen lower Clients mother will be able to Instruct the clients
associated infections.
right quadrant demonstrate techniques and lifestyle mother to wash hands.
Damaged tissue changes to promote safe Provide clean, well- Reduce risk for infection.
environment. Client will achieve ventilated environment. To avoid microbial
afebrile state. Change dressing, as multiplication in the
indicated, using proper area.
technique. To avoid bladder
Maintain adequate distention.
hydration. To prevent more harm
Instruct the clients and infection.
mother to protect the
integrity of the skin, care
of lesions, and prevention
of spread of infection.
Dependent:
To determine
Administer/monitor
effectiveness of therapy.
medication regimen, as
To prevent further
indicated.
infection.
Administer prophylactic
antibiotics and
immunizations, as
indicated.
ACTUAL
NURSING CARE
PLANS
1st Priority
Name: Cardo Dalisay

Nursing Diagnosis: Acute pain related to pain from Congestive heart failure
Assessment Objectives Interventions Rationale Evaluation

Subjective: Short term goal: Independent: Short term evaluation:
Sakit akoang dughan ug At the end of 30 At the end of 30

Assessed pain Assessment of the pain
akong likod maam as verbalized minutes of nursing minutes the patient
characteristics: experience is the first
by the patient intervention the demonstrated-ted Pain
Quality step in planning pain
patient will be able to relief measures
Severity management strategies.
demonstrate Pain
Location Such as Guided
relief measures
Onset Imagery, breathing
Such as Guided Duration exercises, etc.
Imagery, breathing Precipitating or relieving Goals met.
exercises, etc. factors
Objective: Long term goal: Observed and monitored Some people deny the
Angina noted signs and symptoms experience if pain when
Back pain associated with pain, it is present. Attention
Pain scale of 6/10 At the end of 1 hour such as BP, heart rate, to associated signs may
Striking pain of nursing temperature, color and help the nurse in

Long term evaluation:
30 minutes duration of pain intervention the moisture of evaluating pain.
(+) Guarding Behaviour patient will be able to skin, restlessness, and

verbalize adequate ability to focus.
(+) Facial Grimace The patients At the end of 1
relief of pain or ability Provided rest periods to
experience of pain may hour the patient
to cope with facilitate comfort, sleep,
become exaggerated as verbalized pain scale of
incompletely relieved and relaxation
the result of fatigue. 4/10.
of pain.
Goals partially met.
Collaborative:
Determined the
NSAIDS work in
appropriate pain relief
peripheral tissues.
method
Some block synthesis of
4. NSAIDS
prostaglandins, which
stimulate nociceptors.
They are effective in
managing mild to
moderate pain
Nonpharmacological
The use of a mental
methods include the
picture or an imagined
following:
event involves use of
3. Cognitive Behavioral
the five senses to
strategies as follows:
distract oneself from
Imagery
painful stimuli
Distraction
techniques
Relaxation
exercises, breathing
execises, music
theraphy.
4. Cutaneous
Massage decreases
Stimulation as follows
muscle tension and can
Massage of affected promote comfort
area when
appropriate
Gave analgesics as Pain medications are
ordered, evaluating absorbed and
effectiveness and metabolized differently
observing for any signs by patients, so their
and symptoms of effectiveness must be
untoward effects. evaluated individually
by the patient.
2nd Priority
Name: Cardo Dalisay

Nursing Diagnosis: Ineffective breathing pattern related to Hypoxia

Subjective: Short term goal: Independent: Short term
evaluation:
Maintaining the airway
Assessed Airway for
Maglugos man ko ug ginhawa At the end of 2 hours is always the first At the end of 2 hours
patency
labi na pag taggalon ning mask. of nursing intervention priority, especially in of the patient
Murag mahutdan ko ug hangin the patient will be able cases of trauma, acute Demonstrated proper
as verbalized by the patient. to: neurological breathing exercise
decompensation, or
Demonstrate proper And Verbalized
cardiac arrest.
breathing exercise understand-ding
Assessed respirations Respiratory rate and
Verbalized about the importance
rate, rhythm, and depth. Rhythm changes are
understanding about to keep rested to
early warning signs of
the importance to
keep rested to impending respiratory prevent dyspnea
prevent dyspnea difficulties.
Objective: Assessed for the quality, Goals met
Long term goal: This facilities the
Tachypnea RR=35 cpm duration, intensity, and
evaluation of the
regular rhythm At the end of 16 distress associated with
patients response to
Labored breathing hours of nursing dyspnea
therapy and activity
Use of accessory muscles intervention the patient
Specific breathing Long term evaluation:
when breathing will be able to: Monitored breathing
patterns indicate an
patterns: At the end of 16
Nasal flaring noted
Maintain an effective underlying disease
Bradypnea hours of Maintained
Dyspnea noted
breathing pattern as process or dysfunction
Trachypnea an effective breathing
evidenced by relaxed
Hyperventilation pattern as evidenced
breathing at stable
by relaxed breathing
respiratory rate and
Observed for excessive but not stable
minimal or no This is indicative for
use of accessory muscles respiratory rate with
complaints of increased respiratory
when breathing 25cpm and have
dyspnea rate
minimal complaints
Verbalized feeling
Noted retractions or of dyspnea and
comfortable when These signify an
flaring of nostrils verbalized feeling
breathing increase in respiratory
comfortable when
rate
breathing.
Assessed skin color and
Cyanosis occurs when
temperature
at least 5g od Goals partially met.
haemoglobin is
desaturated. Cool pale
skin may be secondary
to a compensatory/
Vasoconstrictive
Response to
Hypoxemia
Collaborative:
Ensured that the oxygen

The appropriate
delivery is applied to the
amount of oxygen is
patient
continuously delivered
so that the patient does
not desaturate.
To maintain the proper

Gave health teaching
inhalation and
about the Proper
exhalation of the
Breathing exercise to the
patient and to
patient with the
significant others and increases oxygenation.
other health care team
Keeping the patient at

Gave health teaching to
comfortable position is
keep rested at
to prevent difficulty of
comfortable position
breathing.
3rd Priority
Name: Cardo Dalisay

Nursing Diagnosis: Imbalanced Nutrition less than body requirements related to unwillingness to eat

Subjective: Short term goal: Independent: Short term
evaluation:
di ko ganahan ug kaon kay dili At the end of 2 hours
Documented actual
ko ka lasa ug tarung as of nursing intervention At the end of 2 hours
weight and height Patients may be
verbalized by the patient the patient will be able of the patient
unaware of their actual
to verbalize proper verbalized proper
weight and height or
selection of foods or selection of foods or
weight loss due to
meals that will achieve a meals that will
estimated weight.
cessation of weight loss. achieve a cessation of
The patient
Assessed for physical weight loss.
encountered nutritional
signs of poor nutritional
deficiencies that Goals met.
intake.
resemble to be sluggish
Long term goal: and fatigued. Other
manifestations include
Objective: Within the end of 16
decreased attention
Anorexia hours of nursing
span, confused, pale
Loss of appetite intervention the patient
and dry skin
Loss of subcutaneous tissue will be able to eat one
subcutaneous tissue
Pale, dry skin whole share of meal
loss, dull and Long term evaluation:
Poor muscle tone with good appetite and
brittle hair. Vital signs
have a weight within the Within the end of 16
BMI=
show tachycardia and
ideal body weight. hours patient able to
Underweight Assessed the patients decrease BP.
eat one whole share
perspective andfeeling The patients perception
of meal with good
toward eating and food. of actual intake may
appetite.
differ.
Assessed etiological Several factors may But the patient is
factors for decreased affect the patients underweight based on
nutritional intake. nutritional intake, so it the BMI.
is vital to assess
properly.
Encouraged the patient to
Determination of type,
recall the food intake and
amount, and pattern of
recorded it.
food or fluid intake is
facilitated by accurate
documentation by the
patient or caregiver as
the intake occurs.
Established appropriate Depending on the
short and long term goal etiological factors of the
problem, movement in
nutritional status may
take a long time.
Suggested ways to assist This is to promote
the patient with meals, as comfort to the patient
needed. Ensure a in the meal time and
pleasant environment, increase its urge to eat.
facilitate proper position, Proper oral hygiene is
and provide good oral to prevent tooth decay
hygiene and dentition. which could lead to low
of appetite.
Discouraged beverages These may decrease
that are caffeinated or appetite and lead to
carbonated early satiety.
Solved the patient Body To ensure that that the
mass index height is appropriate to
weight.
Collaborative:
Obtained nutritional Various psychological,

history; include family, psychosocial, religious,
significant others, or and cultural factors
caregiver in assessment. determine the type,
amount, and
appropriateness of food
utilized.
Assessed for usual food The Food Guide
intake based on the Food Pyramid emphasizes
Pyramid, noting slighted the importance of
or omitted food groups balanced
with the presence of eating. Omission of
Significant others. entire food groups
increases risk of
deficiencies.
Encourage exercise.
Metabolism and
utilization of nutrients
are improved by
activity.
4th Priority
Name: Cardo Dalisay

Nursing Diagnosis: Activity Intolerance
Figure 40.
Subjective: Short term: Dependent: Short Term:
Dili pa ko ka lakaw uyy
Provides
kay tungod sa akong tiil. Evaluated clients
At the end of the 8-hour comparative At the end of the
- As verbalized by actual and
shift, the client will be able baseline and 8-hour shift, the
patient. perceived
to identify negative factors information about client was able to
limitations or
affecting activity intolerance, needed intervention. identify negative
degree of deficit in
use identified techniques to factors affecting her
light of usual
enhance activity intolerance condition, used
Objective: status.
and report measurable Symptoms may be identified
Level IV dyspnea Noted client reports
increase in inactivity contributing to techniques to
and fatigue at rest of weakness,
intolerance. intolerance of enhance activity
fatigue, pain and
difficulty activity. intolerance and
accomplishing reported
Long Term:
tasks. measurable
To determine
Ascertained ability increase in activity
current status and
At the end of the 16- to stand and move intolerance.
needs associated
hour, the client will be able about and degree of
with participation in
to demonstrate a decrease in assistance
desired activities.
physiological signs of necessary of Long Term:
intolerance. equipment.
To prevent
Adjusted activities.
overexertion. At the end of the
16-hour, the client was
Planned care to To reduce fatigue. able to demonstrate a
carefully balance decrease in
rest periods with physiological signs of
activities. intolerance.
Promoted comfort To enhance ability
measures and to participate in
provide for relief of activities.
pain.
Assisted client in To prevent injuries.
learning and
demonstrating
appropriate safety
measures.
Encouraged client To enhance sense of
to maintain positive well-being.
attitude; suggest
use of relaxation
techniques.
Independent:
1. Provided
medications and For therapeutic aid
changes in when needed.
treatment regimen.
5th Priority
Name: Cardo Dalisay

Nursing Diagnosis: Ineffective Tissue Perfusion related to

Provides comparison
1. Noted customary
Gi hangos man ko karon At the end of the 8-hour with current At the end of
baseline data.
uyy. shift, the client will be able to findings. the 8-hour shift,
2. Noted mentation.
verbalize understanding of May be altered by the client was able
- As verbalized by
condition, therapy regimen and increased BUN/Cr. to identify negative
patient
when to contact healthcare 3. Reviewed results of To determine factors affecting
provider. diagnostic studies. location/severity of her condition,
condition. used identified
4. Monitored for May indicate techniques to
temperature, ischemic colitis. enhance activity
Objective: especially in intolerance and
presence of bright reported
red stool. measurable
Oliguria
5. Elevated HOB and To promote increase in activity
Anuria
maintain head in circulation/venous intolerance.
Hematuria
midline or neutral drainage.
Restlessness
position.
Dysphagia
6. Encouraged rest To maximize blood Long Term:
Arrythmias flow to stomach.
after meals.
Use of accessory 7. Encouraged early Enhances venous
At the end of the
muscles ambulation, when return.
16-hour, the client
Altered mental status possible.
was able to
Hypoactive bowel 8. Encouraged Smoking causes
demonstrate a
sounds smoking cessation. vasoconstriction.
decrease in
Altered skin
physiological signs of
characteristic Long Term:
Independent: intolerance.
Altered sensations
Edema
At the end of the 16-hour, 1. Administered
Delayed healing the client will be able to May be used to
medications with
demonstrate behaviors/lifestyle decrease edema.
caution.
changes to improve circulation Drugs used to
and demonstrate increased improve tissue
perfusion as individually perfusion also carry
appropriate. risk of adverse
responses.
2. Assisted with
treatment of To improve organ
underlying function.
conditions.
6th Priority
Name: Cardo Dalisay

Nursing Diagnosis: Excess Fluid Volume
For presence of
Auscultated breath
Ga lisod ko ginhawa At the end of the 8-hour crackles/congestion. At the end of the 8-
sounds.
kung mag tindog or shift, the client will be able hour shift, the client
lakaw ko. to verbalize understanding was able to verbalized
Evaluated For confusion or
of individual dietary/fluid understanding of
- As verbalized mentation. personality changes.
restrictions. individual dietary/
by patient Elevated To reduce tissue
fluid restrictions.
edematous pressure and risk of
extremities, change skin breakdown.
position frequently.
Long Term:
Objective: Long Term: Placed in semi- To facilitate
fowlers position, as respiratory effort.
At the end of the 16-
appropriate.
Edema At the end of the 16- hour, the client was able
Suggested To reduce discomfort
Oliguria hour, the client will be able to stabilized fluid volume
interventions, such of fluid restrictions.
Adventitious to stabilize fluid volume as as evidenced by balanced
as oral care.
breath sounds evidenced by balanced I/O, I/O, vital signs within
Change in vital signs within clients clients normal limits, has
mental status; normal limits and free of Independent: reduced edema and
restlessness signs of edema and demonstrated behaviors

demonstrate behaviors to Administered May be used to to monitor fluid status
monitor fluid status and medications with decrease edema. and reduce recurrence of
reduce recurrence of fluid caution. fluid excess.
excess.
7th Priority
Name: Cardo Dalisay

Nursing Diagnosis: Reference: Doenges, M.E., Moorhouse, M. F. and Murr, A. C. (2012). Nursing Care Plans, Guidelines for
Individualizing Client Care Across the Life Span. 14th ed. P. 472. F. A. Davis Company; Pennsylvania.

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NURSING CARE

Name: Cardo Dalisay

Assessment Objectives Interventions Rationale

Respiratory depth monitoring or

changes arterial blood gases (ABGs)

abdominal breathing ventilation.

performing relaxation techniques

Name: Cardo Dalisay

Assessment Objectives Interventions Rationale

metabolic needs in excess good appetite. signs may show tachycardia

Diarrhea and/or body weight. Paresthesias may also be

Excessive hair loss

feeling toward eating and food. psychosocial, religious, and

5. Ascertain etiological factors for Several factors may affect

6. Encourage the patient to recall the

This is to promote comfort

Family members may

11. Ascertain healthy Experts like a dietician can

12. Encourage exercise. Metabolism and utilization

13. Consult dietician for further Dieticians have a greater

Name: Cardo Dalisay

Assessment Objectives Interventions Rationale

such as BP, heart rate, present. Attention to

Alteration in muscle tone: or ability to cope with incompletely therapies

Autonomic response exaggerated as the result of

Determine the appropriate pain

Gave analgesics as ordered,

Name: Cardo Dalisay

Assessment Objectives Interventions Rationale

Name: Cardo Dalisay

Arrhythmias 6. Elevate HOB and To promote

Use of accessory muscles maintain head in circulation/venous

Altered mental status midline or neutral drainage.

Hypoactive bowel sounds position.

Altered skin characteristic 7. Encourage quiet, restful Conserves energy.

May be used to decrease

Name: Cardo Dalisay

Assessment Objectives Interventions Rationale

Name: Cardo Dalisay

These affects the clients

Name: Cardo Dalisay

Assessment Objectives Interventions Rationale Evaluation

Sakit akoang dughan ug At the end of 30 At the end of 30

Striking pain of nursing temperature, color and help the nurse in

(+) Guarding Behaviour patient will be able to skin, restlessness, and

Name: Cardo Dalisay

Assessment Objectives Interventions Rationale Evaluation

Ensured that the oxygen

To maintain the proper

Keeping the patient at

Name: Cardo Dalisay

Assessment Objectives Interventions Rationale Evaluation

Obtained nutritional Various psychological,

Name: Cardo Dalisay

changes in when needed.

Name: Cardo Dalisay

Assessment Objectives Interventions Rationale Evaluation

Name: Cardo Dalisay

Assessment Objectives Interventions Rationale Evaluation

Subjective: Short term: Dependent: Short Term:

Change in vital signs within clients clients normal limits, has

restlessness signs of edema and demonstrated behaviors

Name: Cardo Dalisay