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PLANNING (NURSING CARE PLANS)

Problem No. 1 Hyperthermia

Assessment Nursing Scientific Objectives Interventions Rationale Expected


Diagnosis explanation Outcome
S>ø Hyperthermia Dengue Short term: >Establish good >to gain Short term:
O> patient related to Hemorrhagic After 4 hours of working patient’s trust The patient’s
manifested: inappropriate Fever is Nursing condition with body
>Flushed warm clothing factor potentially Interventions the the pt and SO. temperature
skin as evidenced by deadly patient’ will be shall have a
>Increase decrease in complication that maintaining a >monitor v/s q >to have maintained
Temp. of platelet count. is characterized normal body 2hours. baseline data normal body
O
38.5 C by high fever. temperature. temperature.
>irritability Hyperthermia is >provide TSB >to maintain a
>Diaphoresis an abnormal rise normal body
patient may in the temperature.
manifest: temperature of Long Term:
 Increased the human body. After 4 days of >Encourage >to replace fluid
PR Normal body NI, the patient increase fluid loss Long Term:
 Increased temperature is will experience intake After 4days of
O
RR 98.6 F or 37.5 no associated NI, the patient
O
 Seizure C. Fever may complications >Encourage >to boost body will experience
 Muscle not result only such as seizures food rich in resistance to no associated
rigidity from a etc. Vitamin C infection complications
disturbance of such as seizures
heat-regulating >provide client >to prevent etc.
mechanism of safety further injuries
the body but
also through
disturbances of >maintain bed >to preserve
the blood, the rest energy
rate of breathing.
Indeed there are
oral intake
during periods of
illness will result
to further body
weakness
impairing the
patient’s ability
to perform usual
routines and
ADL’s

Problem No. 2 ineffective tissue perfusion related to decrease hgb concentration


Assessment Nursing Scientific Objectives Interventions Rationale Expected
Diagnosis explanation Outcome
S>ø ineffective tissue Due to the Short term: > Establish good >to gain Short term:
O> patient perfusion related replication of After 3 hours of working patient’s trust After 3 hours of
manifested: to decrease hgb dengue virus in Nursing condition with Nursing
>appears pale concentration the body, there Interventions the the pt and SO Interventions the
and weak could be patient’ will patient shall
>flushed palms stimulation of demonstrate >Assess the >to have have
and soles production of behaviors that patient’s baseline data demonstrated
kinine causing will improve thee condition behaviors that
increase tissue perfusion. will improve thee
vascular > Monitor vital >needed for tissue perfusion.
permeability signs ongoing
leading to Long Term: comparison Long Term:
capillary After 2-3 days of After 2-3 days of
damage. Thus NI, the patient >assess for >early detection NI, the patient
will cause will demonstrate possible of cause shall have
internal increase tissue causative factors facilitates demonstrated
bleeding. This perfusion AEB r/t temporarily prompt, effective increase tissue
was manifested normal Hgb level impaired arterial treatment perfusion AEB
through flushed count blood flow normal Hgb level
palms and soles count
and appearance >Monitor quality >loss of
of brownish of all pulse peripheral
purplish rashes pulses must be
on the reported or
extremities treated
immediately

>maintain >to increase


optimal cardiac cellular oxygen
output supply

>review lab >to evaluate the


values and note importance of
customary NI’s given and
baseline data provide
comparison by
current findings

Problem # 3: Risk for injury r/t abnormal blood profile as evidenced by decrease platelet count
Assessment Nursing Scientific Objectives Interventions Rationale Expected
Diagnosis explanation Outcome
S>ø Risk for Risk of Injury as Short term: >Establish rapport >to gain Short term:
O> patient injury r/t a result of After 4 hours of patient’s trust After 4 hours of
manifested the abnormal environmental Nursing Nursing
following which put blood profile conditions Interventions, >Assess level of >assist in Interventions,
his at risk for injury as evidenced interacting with pt will consciousness determining pt. pt will have
 Low platelet by decrease the individuals demonstrate and cognitive ‘s ability to demonstrate
count platelet adaptive and techniques level protect self techniques
 Abnormal count. defensive behavior, and comply behavior,
blood profile resources. It is lifestyle with required lifestyle
 Tissue also because of changes to risk self protective changes to risk
Hypoxia the infection of factors and actions factors and
Pt may manifest DHF I Virus that protect self. protect self.
 Sensory destroys the
dysfunction platelets which Long Term: Long Term:
 Broken Skin place the After 1 days of >Provide safe > Minimizes After 1 days of
 Malnutrition patient at risk of NI, the patient’ environment (pad, injury to occur NI, the the
bleeding. When will be free side rails, prevent patient’ will
the blood from injury. falls) have been
vessels are cut free from
or damage , the > Observe for > Permits injury.
loss of blood each stool color, detection of
from the system consistency and bleeding in GI
must be stop amount tract
before shock
and possible >Observe for > Indicate
death may hemorrhagic altered clotting
occur. This is manifestation, mechanism
accompanied ecchymosis,
by solidification epistaxis,
of the blood, a Petechiae, and
process called bleeding gums
coagulation or
clotting. If the
value should
stop below >Encourage > Promotes
normal, intake of foods healing and
(150,000 with high content boost the
-450,000 g/dl), of Vit. C resistance of
there is a the body
danger of against
uncontrolled infection
bleeding
because of the > Assess pt’s > To obtain
essential role condition and baseline data
that platelets monitor vital
have in blood signs.
clotting.
> Provide comfort > To promote
measures, such relaxation and
as stretching bed alleviate .
linens.

> Avoid SC, IM > Minimizes


route of injection tendency of
as possible trauma or
bleeding
Problem # 4: Risk for constipation related to irregular defecation habits as evidence by defecate once or twice per week

Assessment Nursing Scientific Objectives Interventions Rationale Expected


Diagnosis explanation Outcome
S=Ø
Risk for Irregular ST Provide To ease ST
O= patient constipation defecation comfortable patient’s
manifested by: related to habits of one or After 3 hrs of environment anxiety and to Patient shall
 irregular irregular two times per nursing help the have
defecation defecation week may interventions patient recover demonstrate
habits habits as cause the stool patient will faster for behavior
 inadequate evidence by to harden and demonstrate proper hygiene changes to
toileting defecate dry. It may also behaviors of the patient developing

 recent once or twice cause infection changes to problem

environmental per week which may lead developing

changes to constipation problem Provide comfort For proper LT

 >change in measures by AM hygiene of the

usual eating LT: care, changing patient Patient shall

pattern the linen and have improve

 >ignoring urge After 2 hrs of touch therapy her bowel

to defecate nursing pattern


interventions Provide safety by To avoid
patient will placing pillows at patient from

Patient may improve her the side of the injury

manifested by: bowel pattern bed


 >dehydration
 >electrolyte VS monitor and To have
imbalance change baseline data

 >decrease
motility of
gastro
intestinal troat Auscultate Reflecting

 >hemorrhoids abdomen for bowel activity

Insufficient presence, location

physical and

activity characteristics of
bowel sounds

Review For impact


medication effect of
change in
bowel function

Encourage To improve
balance fiber and consistence of
bulk habit the stool and
facilitate
passage
through colon
Promote To promote
adequate fluid soft stool and
intake, including stimulate
water and high- bowel activity
fiber fruit juice;
also suggest
drinking warm
fluid

Ascertain Provide as
frequency, color, baseline of
consistence, comparison,
amount of stools promotes
recognition of
changes

Educate client/SO Information


about safe and can help client
risky practice for to make
managing beneficial
constipation choices when
needed
Review medical/ To identify
surgical history condition
commonly
associated
with
constipation

Review To determine if
appropriate use of drugs
medication. contributing to
Discuss client’s constipation
current can be
medication discontinue or
regimen with change
physician

Problem # 5 Impaired tissue integrity related to mechanical and chemical factor of IV infusion and blood test; secondary to haematoma
as evidence by collection of blood on the upper extremities.
Nursing Scientific Expected
Assessment Diagnosis Explanation Objectives Interventions Rationale Outcome
Provide To ease patient’s
S=Ø Impaired Hematoma is a ST comfortable anxiety and to help ST
O= patient tissue localized After 4 hrs of environment the patient recover
manifested by: integrity collection of nursing faster for proper Patient shall
 pallor related to blood, usually interventions hygiene of the have
 haematoma mechanical clotted, in a tissue patient will patient demonstrate
on both and chemical or organ. demonstrate behavior to
upper factor of IV Hematomas can behavior to Provide comfort For proper hygiene reduce
extremities infusion and occur almost reduce the measures by AM of the patient hematoma

 weakness blood test; anywhere on the hematoma care, changing the

 impaired secondary to body. In minor LT linen and touch LT

circulation haematoma injuries, the blood After 2 weeks therapy


as evidence is absorbed of nursing Patient shall
 damage
by collection unless infection interventions have reduce
tissue
of blood on develops. One of presence of Provide safety by To avoid patient from presence of
the upper the signs of hematoma will placing pillows at injury haematoma
extremities. haematoma is be reduce the side of the bed
Patient may
collection of blood
manifested by:
in the peripheral Encourage To limit metabolic
 fluid deficit
area it may be adequate periods demands, maximize
 infection
seen in the upper of rest and sleep energy and meet
 acute pain
extremities. comfort needs
 change in
Mechanical and
turgor
chemical factors
 edema
like IV infusion VS monitor and To have baseline
and blood test change data
may cause
haematoma.which Identify underlying Suggest treatment
leads to impaired condition involves options, desire/ability
tissue integrity. in tissue injury to protect self and
potential to
recurrence of tissue
damage

Assess To comparative
skin/tissues, bony baseline
prominences,
pressure areas and
wounds

Inspect Promote timely


lesions/wounds interventions/revision
daily, or as of plan of care
appropriate, for
change

Monitor laboratory To changes


studies indicative of healing
or infection
complications
Help client and To reduce discomfort
family to identify and improve quality
effective successful of life
coping
mechanisms and to
implement them

Discuss importance Promotes early


of early detection interventions/
and reporting of reduces potential
changes in complications
condition or any
unusual physical
discomforts

Emphasize need to Optimize healing


adequate potential
nutritional/fluid
intake

Provide warm To improve


compress circulation