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Far Eastern University

Institute of Nursing

Nursing Care Plan

Cues Nursing Rationale Goal and Interventions Rationale Evaluation


Diagnosis Objectives

Deficient Situational Analysis Goal: Goal met.


fluid volume Water content of the After an 8-hour After an 8-
Observation: related to human body progressively shift, client will be hour shift,
fever, decreases from birth to old able to client was
-Client appeared vomiting age. In the neonate, fluid demonstrate able to
irritable. and accounts for as much as adequate fluid demonstrate
excessive 75% of body weight. Most balance as adequate fluid
perspiration. of the decrease occurs in evidenced by balance as
-Client is with fair the first 10 years of life. good skin turgor, evidenced by
reflexes. Hypovolemia or extra moist skin and good skin
cellular fluid volume deficit mucous turgor, moist
-Client has poor skin is the isotonic loss of body membranes; skin and
turgor assessed at the fluids, that is, relatively caregiver will be mucous
abdomen. equal losses of sodium able to verbalize membranes;
and water. understanding of caregiver will
-Client has unsunken child’s fluid needs be able to
eyes and fontanels. Pediatric clients are more and will be able to verbalize
at risk of hypovolemia and demonstrate understanding
-Client has moist skin dehydration because their behaviors to of child’s fluid
folds including the bodies need to have a prevent needs and will
antecubital fossa. higher proportion of water development of be able to
to total body weight. fluid volume demonstrate
-Client has dry mucous Excessive fluid loss deficit. behaviors to
membranes including reduced fluid intake, third- prevent
the buccal and oral space fluid shift, and a development
mucosa. combination of these Objectives: of fluid
factors causes fluid volume
volume loss. Fluid loss deficit.
causes include abdominal Facilitative
-Client passed out stool surgery, diabetes mellitus, 1.The causative 1.Causative/contributing Objective
1.Note potential sources factors for fluid
once in the morning. diarrhea, vomiting, or precipitating of fluid loss/intake. met.
imbalances.
Stool was semi-soft, excessive diuretic therapy, factors that cause
yellow in color and not excessive use of laxatives, the client’s 2.Indicators of hydration
watery. excessive perspiration and condition & the 2.Continue monitor the status. Note:
crying, fever, fistulas, degree of fluid vital signs, mucous Hypotension indicative
hemorrhage, nasogastric deficit will be membranes, weight, of developing shock
BP= 120/80 mmHg CR= drainage and renal failure evaluated. skin turgor, breath may not be readily
90bpm PR= 20cpm with polyuria. sounds, urinary and observed in pediatric
gastric output.
Temp: 37.8c. patients until very late in
the clinical course.
Fluid shift related to burns
during the initial phase, 4.Review patient’s 4.Provides baseline and
vomiting, acute intestinal intake of fluids. Hydrate comparison
obstruction, acute gastro with water after every
enteritis, acute peritonitis, feeding.
crushing injury, hip or
pelvic fracture (1.5 to 2 L 5.Determine child’s 5.Provides information
normal pattern of for baseline and
of blood may accumulate
elimination. comparison.
in tissues around the
fracture), pancreatitis and
6. Continue monitor the 6. Consistency with
pleural effusion may also
patient’s weight and weight measurement
contribute to fluid volume
compare the result on helps ensure more
deficit. Another possible
the next days. Weigh on accurate results. Weight
causes of reduced fluid
the same scale at the is a useful indicator of
volume are dysphagia,
same time of day & fluid balance. Weight
coma, environmental
wearing same amount loss indicates that child
conditions preventing fluid
of clothing is not receiving
intake and psychiatric
adequate fluid
illness.
replacement and
adjustments need to be
made.
Health Implication Supplemental
Hypovolemia is an isotonic
disorder. Fluid volume 1.Administer and
monitor IV fluids as 1. Provides fluid & nutritional
deficit decreases capillary support to replace active fluid
hydrostatic pressure and ordered.
loss.Close monitoring
fluid transport. Cells are and regulation is
deprived of normal required to prevent fluid
nutrients that serve as overload while
substrates for energy correcting fluid balance.
production, metabolism,
and other cellular 2.Request for laboratory
functions. Decreased renal 2.After 30 results, e.g., 2.Indicators of
blood flow triggers the minutes of hemoglobin/hematocrit adequacy of
rennin-angiotensin system nursing care, the (Hb/Hct), BUN, urine hydration/therapeutic
to increase sodium-water client will be able osmolality/specific interventions.
reabsorption. The to elicit no signs gravity.
cardiovascular system of dehydration.
compensates by Developmental
increasing heart rate, 1. Instuct the caregiver
cardiac contractility, to apply moist towel on 1. Moist towel may
venous constriction, and client’s lips when noted reduce the dryness of
systemic vascular dry. the oral musosa.
resistance, thus increasing
Facilitative
cardiac output and mean 1. Provide fresh water
arterial pressure. and oral fluids preferred 1. The oral route is
by the client (distribute preferred for
over 24 hours) provide maintaining fluid
It also triggers the thirst prescribed diet; offer balance Distributing the
response, releasing more snacks. Instruct intake over the entire
antidiuretic hormone and significant other to 24-hour period and
producing more assist the client with providing snacks and
aldosterone. When feedings as appropriate. preferred beverages Objective
compensation fails, 2. After 15 increases the likelihood met.
hypovolemic shock occurs minutes of that the client will
in the following sequence: nursing maintain the prescribed
intervention, client oral intake.
-decreased intravascular will be able to 2.Auscultate bowel
fluid volume feed with ease sounds. Note 2.Provides information
and without characteristics of stool about digestion/bowel
-diminished venous return, undue discomfort. (color, amount, function and may affect
which reduces preload frequency, and so on). choice/timing of
and stroke volume feeding.
Facilitative
-reduced cardiac output
1. Provide frequent oral
-decreased mean arterial hygiene, at least twice a 1. Oral hygiene
pressure day decreases unpleasant
tastes in the mouth and
-impaired tissue perfusion allows the client to
2. Provide comfort respond to the
-decreased oxygen and measures (e.g. clean sensation of thirst.
nutrient delivery to cells, cloth, clean linens, etc.)
3.Provide a quiet
-multiple organ 3. After 15 environment.
dysfunction syndrome minutes of 2. Promotes comfort
nursing level & distraction.
Possible complications of intervention, client Objective
Developmental
hypovolemia include will be able to met.
shock and acute renal comfortable and 1.Educate caregiver 3.Quiet environment
failure. manifest no signs factors contributing to promotes good rest and
of irritability and dehydration, comfort.
will be able to rest complications of
(Lippincott Manual of comfortably. dehydration, signs of
Nursing Practice Series dehydration and 1.Ensures continued
Pathophysiology; 2007; different ways in preventive measures in
pp.458-461) preventing dehydration. home setting.

(Pediatric Nursing Care


Plans; Swaeringer;
2006; pp.674-676)
(Fundamentals of Nursing; Objective
4. After 20 Taylor et. al.; 5th Edition; 2005) met.
minutes of
nursing
action,patient will
be able to
enumerate at
least 3 out 5
infant care
measures of
preventing
dehydration.

Cues Nursing diagnosis Rationale Goals & Objectives Intervention Rationale Evaluation
Subjective: Risk for This infectious After 8 hrs. Of Goal met.
“Isang araw parang Bleeding disease is nursing After 1 hr. Of
dumugo ilong ko related to manifested by interventions, nursing
pero konting konti altered clotting a sudden the client will interventions,
palang naman”as factor. onset of fever, be at reduced risk the client
verbalized by the with severe for bleeding was able to
Patient. headache, demonstrate
muscle and behaviors
Objective: joint pains that reduce
· Weakness and (myalgias and the risk for
irritability. arthralgias— bleeding.
severe pain
· Restlessness. gives it the
name breakbone
· V/S taken as fever or
follows: bonecrusher
BP= 120/80 mmHg disease) and
CR= 90bpm rashes and
PR= 20cpm usually Objectives:
Temp: 37.8c. appears first 1.After 3 hours of Independent: The G.I tract Objective met.
on the lower nursing intervention · Assess for signs (esophagus and
limbs and the the patient will be and symptoms of rectum) is the
chest. There able to identify G.I bleeding. most usual
may also be factors that could Check for source of
gastritis and increase risk of secretions. bleeding of its
some times bleeding. Observe color mucosal
bleeding. and consistency fragility.
of stools or
vomitus. · Sub-acute
· Observe for disseminated
presence of intravascular
petechiae, coagulation
ecchymosis, (DIC) may
bleeding from one develop
more sites. secondary to
altered clotting
factors.

· Monitor pulse, · An increase in


Blood pressure. pulse with
decreased
Blood pressure
can indicate
loss of
circulating
blood volume.
· Note changes in · Changes may
mentation and indicate
level of cerebral
consciousness. perfusion
secondary to
hypovolemia,
hypoxemia.
2.After 3 hours of · Avoid rectal · Rectal and
Nursing intervention, temperature, be esophageal Objective met
the patient will be gentle with GI vessels are
able to demonstrate tube insertions. most vulnerable
ways to reduce risk to rupture.
for bleeding.
· Encourage use of · In the presence
soft toothbrush, of clotting factor
avoiding straining disturbances,
for stool, and minimal trauma
forceful nose can cause
blowing. mucosal
bleeding.
· Use small
needles for · Minimizes
injections. Apply damage to
pressure to tissues,
venipuncture reducing risk for
sites for longer bleeding and
than usual. hematoma.

· Recommend
avoidance of · Prolongs
aspirin containing coagulation,
products. potentiating risk
of hemorrhage.
Collaborative:
· Monitor Hb and
Hct and clotting · Indicators of
factors. anemia, active
bleeding, or
impending
complications

Cues Nursing Analysis Goals and Nursing interventions Rationale Evaluation


diagnosis objective
Subjective: Acute Pain Acute pain is an GOAL:
Complaining for (+) pain in related to IV unpleasant sensory and After 2 hours Goal met. The
her IV insertion site and medication/side emotional experience of student client was able
arms.. drip of KCL arising from actual or nurses’ to experienced
potential tissue damage or intervention the gradual
“Ang sakit sakit niya siguro described in terms of such patient’s pain reduction or
dahil sa gamut o kaya damage ; sudden or slow scale will be relief of pain as
baka wala na sa linya ung onset of any intensity from reduced by two evidenced by
IV,” as verbalized by the mild to severe with an while on KCL decreased pain
patient. anticipated or predictable side drip scale from 5/10
end and a duration of less to 2/10, having
A pain scale of 5/10 than six months. Acute OBJECTIVES: Facilitative: normal BP and
pain, which usually occurs After 30 Assess nature and These data provide PR, and
Objective: in response to tissue minutes of degree of discomfort. information about the verbalization of
injury, results from assessment subjective experience reduction of
Grimacing upon touching activation of peripheral with the patient, of discomfort for this pain. The client
of arm pain receptors and their the patient will client. was also able to
specific A delta and C be able to identify 1 cause
Tender to touch and warm. sensory nerve fibers identify at least of pain, and
With slight inflammation. (nociceptors). ways of pain Assess blood pressure Provides baseline choose and
reduction. and pulse and IV site. and comparison apply one way
Pain fibers enter the spinal to alleviate pain.
cord at the dorsal root
BP= 120/80 mmHg CR= ganglia and synapse in the Supplemental and
90bpm PR= 20cpm Temp: dorsal horn. From there, Developmental:
37.8c. fibers cross to the other Assist with measures
side and travel up the that reduce discomfort.
lateral columns to the These include:
thalamus and then to the • Discussion and Reduces discomforts.
cerebral cortex. demonstration
to the client
Repetitive stimulation (eg, breathing
from a prolonged painful relaxation
condition) can sensitize techniques and
neurons in the dorsal horn encouraging
of the spinal cord so that a use of
lesser peripheral stimulus breathing/relax
causes pain (wind-up ation
phenomenon). Peripheral techniques.
nerves and nerves at other
levels of the CNS may • Warm to cold Ice provides local
also be sensitized, compress anesthesia, promotes
producing long-term vasoconstriction, and
synaptic changes in reduces edema
cortical receptive fields formation
(remodeling) that maintain
exaggerated pain
perception. • Reduction of Pain may be
stimulation in associated with
Substances released the anxiety; blood
when tissue is injured, environment pressure and pulse
including those involved in are elevated with
the inflammatory cascade, anxiety.
can sensitize peripheral
nociceptors. These • Provision of Divert pain to other
substances include arm rubs stimulation/sensation.
vasoactive peptides (eg, Provides relaxation.
calcitonin gene-related
protein, substance P, • Teach Forget about the
neurokinin A) and other Diversional feeling of pain by
mediators (eg, activities like focusing on other
prostaglandin E2, sleeping, activities
serotonin, talking with
bradykinin, epinephrine). company,
reading books.

After 2 ½ Facilitative:
hours of Institute comfort Promotes comfort
discussion and measures
demonstration -Warm to cold
to the patient, Compress
the patient will - Slight Arm rubs
be able to apply
at least one
way to alleviate
pain Collaborative Analgesics act on
Administer analgesic as higher brain centers
needed. Assess to reduce perception
effectiveness of pain of pain, promoting
medication. Explain relaxation, facilitating
action of analgesic, rest and sense of
time factors and well-being.
restrictions. Knowledge of typical
After 3 hours of effect aids in
intervention the developing realistic
client will be expectations.
able to Knowledge of time
verbalize restrictions, with
improved reasons, allows client
comfortability. compliance with
orders.