NURSING CARE PLAN 1 - DIARRHEA

ASSESSMENT NURSING INFERENCE PLANNING/G NURSING RATIONALE EVALUATION

DIAGNOSIS OAL INTERVENTION

INDEPENDENT:
SUBJECTIVE: • Diarrhea • Diarrhea is the • After 4 • Observe and • Helps • After 4
related to passage of hours of record stool differentiate hours of
“Madalas akong presence of loose and nursing frequency, individual nursing
dumumi ngayon toxins. watery stools interventio characteristics, disease and interventio
kaysa kahapon” (more than 3 ns, the amount and assesses ns, the
as verbalized by bowel patient will precipitating severity of patient
patient. movements report factors. episode. was able to
per day) often reduction report
OBJECTIVE: associated in • Promote reduction
with frequency bed rest. in
• Frequent gassiness, of stools. frequency
watery stools. bloating, and • Rest decreases of stools.
• Abdominal abdominal intestinal
pain. pain. It may • Provide motility and
• V/S taken as also be bedside reduces
follows: accompanied commode. metabolic rate.
by nausea, • Urge to
vomiting, and defecate may
T: 36.6 fever. Diarrhea occur without
P: 80 results to loss warning and
R: 18 of body fluids uncontrollable,
Bp: 110/90 and salts increasing risk
leading to • Identify of incontinence
dehydration of foods and fluids or falls if
varying that precipitate facilities are
severity. diarrhea. not close at
Severe hand.
dehydration • Avoiding
may cause • Restart oral intestinal
death fluid intake irritants
especially in gradually. Offer promotes
children
 clear liquids intestinal rest.
hourly, and
avoid cold
fluids.
• Provides colon
rest by omitting
or decreasing
stimulus of
foods or fluids.
Gradual
consumption of
liquids may
• Encourage prevent
to eat foods cramping and
like banana and recurrence of
apple. diarrhea. Cold
• Avoid foods fluids can
that are oily, increase
spicy and intestinal
caffeine. motility.

COLLABORATIVE: • Fruits that are

stool former.
• Administer
anti-diarrheals • Foods that
as prescribed may precipitate
by the gastric
physician. cramping.

• Decreases G.I
motility or
peristalsis and
diminishes
digestive
secretions to
relieve
 cramping and
diarrhea.

NURSING CARE PLAN 2 – TYPHOID FEVER

ASSESSMENT NURSING INFERENCE PLANNING/G NURSING RATIONALE EVALUATION
DIAGNOSIS OAL INTERVENTION

INDEPENDENT:
SUBJECTIVE: • Hyperther • Typhoid fever • After 7 • Monitor patient • Fever • After 7
mia related is a bacterial days of temperature pattern may days of
“Mainit ang to disease, nursing degree and aids in nursing
pakiramdam ko” increased caused by interventio patterns. diagnosing interve
as verbalized by metabolic Salmonella ns, the underlying ntions,
patient. rate, typhi patient will • Observe for disease. the
illness. . It is demonstrat shaking chills patient
OBJECTIVE: transmitted e and profuse was
through the temperatur diaphoresis. • Chills often able to
• Flushed skin, ingestion of e within precede during demons
warmed to food or drink normal high trate
touch. contaminated range and temperature temper
• Restlessness. by the feces or free from • Wash hands and in ature
• V/S taken as urine of chills. . with anti- presence of within
follows: infected bacterial soap generalized normal
people. before and infection. range
T: 38.9 Symptoms after each care and
P: 80 usually of activity and • Reduces free
R: 21 develop 1–3 encourage cross from
Bp: 100/80 weeks after proper hygiene. contamination chills.
exposure, and and prevents
may be mild or • Provide tepid the spread of
severe. They sponge baths infection.
include high and avoid the
fever, malaise, use of ice water
headache, and alcohol.
constipation or
diarrhea, rose- • May help
colored spots reduce fever.
on the chest, • Monitor for Use of ice
and enlarged signs of water and
spleen and deterioration of alcohol may
liver. Healthy condition or cause chills and
carrier state failure to can elevate
may follow improve with temperature.
acute illness. therapy.
Typhoid fever • May reflect
can be treated COLLABORATIVE: inappropriate
with antibiotic
antibiotics. • Administer therapy.
However, anti-pyretics as
resistance to prescribed.
common
antimicrobials • Administer
is widespread. anti-biotics as
Healthy prescribed. • Used to
carriers should reduce fever by
be excluded its central
from handling action on the
food. hypothalamus.
• To control the
spread of
infection.
 NURSING CARE PLAN 3 - HYPERTENSION
ASSESSMENT NURSING INFERENCE PLANNING/G NURSING RATIONALE EVALUATION
DIAGNOSIS OAL INTERVENTION
INDEPENDENT:
SUBJECTIVE: • Risk for • High blood • After 8 • Define and • Provides basis • After 8
prone pressure (HBP) hours of state the limits for hours of
“Bakit kaya behavior or nursing of desired BP. understanding nursing
madalas ako related to hypertension interventio Explain elevations of interventio
mahilo?” lack of means high ns, the hypertension BP, and ns, the
as verbalized by knowledge pressure patient will and its effect clarifies patient
the patient. about the (tension) in verbalize on the heart, misconceptions was able to
disease. the arteries. understand blood vessels, and also verbalize
OBJECTIVE: Arteries are ing of the kidney, and understanding understand
vessels that disease brain. that high BP ing of the
• Agitated carry blood process can exist disease
 behavior from the and without process
• Inaccurate pumping heart treatment symptom or and
follow to all the regimen. even treatment
through of tissues and • Assist the when feeling regimen.
instructions. organs of the patient in well.
• V/S taken as body. High identifying
follows: blood pressure modifiable risk • These risk
does not mean factors like diet factors have
T: 37.2 excessive high in sodium, been shown to
P: 84 emotional saturated fats contribute to
R: 18 tension, and hypertension.
BP: 170/100 although cholesterol.
emotional
tension and
stress can • Reinforce
temporarily the importance
increase blood of adhering to • Lack of
pressure. treatment cooperation is
Normal blood regimen and common
pressure is keeping follow reason for
below 120/80; up failure of
blood pressure appointments. antihypertensiv
between e therapy.
120/80 and
139/89 is
called "pre- • Suggest
hypertension", frequent
and a blood position • Decreases
pressure of changes, leg peripheral
140/90 or exercises when venous pooling
above is lying down. that may be
considered potentiated by
high. An vasodilators
elevation of and prolonged
the systolic sitting or
and/or • Help patient standing.
diastolic blood identify sources
pressure of sodium • Two years on
increases the
risk of intake. moderate low
developing salt diet may
heart (cardiac) be sufficient to
disease, control mild
kidney (renal) • Encourage hypertension.
disease, patient to
hardening of decrease or • Caffeine is a
the arteries eliminate cardiac
(atherosclerosi caffeine like in stimulant and
s or tea, coffee, may adversely
arteriosclerosi cola and affect cardiac
s), eye chocolates. function.
damage, and
stroke (brain
damage). • Stress
These importance of • Alternating rest
complications accomplishing and activity
of daily rest increases
hypertension periods. tolerance to
are often activity
referred to as progression.
end-organ COLLABORATIVE:
damage • Provide • Community
because information resources like
damage to regarding health centers
these organs community programs and
is the end resources, and check ups are
result of support helpful in
chronic (long patients in controlling
duration) high making lifestyle hypertension.
blood changes.
pressure.