122

NURSING CARE PLAN (1)

Intervention
Diagnosis Need Desired Outcome Intervention Rationale Evaluation Rationale
Modification
Excess Fluid Volume Within 8 hrs of
related to Sodium and P appropriate nursing
Water Retention as H intervention, the
manifested by Y patient will be able
massive abdominal S to:
ascites I
O General:
Subjective L
Cue: O Maintain fluid
“Pag dili ko maka-ihi, G volume balance
nagapang-hubag I
akong tiil pababa ” as C
patient verbalized. Specific: Independent:
N
E 1. Stabilize fluid establish rapport -to gain the patient’s Goal met: Continue Continuity
Objective Cues: E volume as trust and cooperation patient able nursing of care
-abdominal D evidenced by to stabilize intervention helps
enlargement (98cm) Balance fluid volume maintain
-decreased intake and the body
hemoglobin (60 g/L) output fluid
-dependent edema values. -to avoid deficit or balance.
-regulate IVF at excess of fluid in the
desired rate body
Background
Knowledge:
Renal failure results
when the kidneys Monitor Intake and To monitor the fluid
cannot remove the output and electrolyte
body’s metabolic balance
wastes or perform
their regulatory
 123

functions. The
substances normally -Assess degree of -Edema is a primary
eliminated in the urine fluid volume excess sign of excess fluid
accumulate in the by noting presence of volume in the body,
body fluids as a result edema on face, assessing it will note
of impaired renal peripheral the degree of extent
excretion leading to a extremities, lungs of fluid volume.
disruption in the and prominent bony
endocrine and structures.
metabolic functions as
well as fluid,
electrolyte and acid- -Note patterns and -Urination is a way of
base disturbances. amount of urination. the body to excrete
excess fluid from the
Reference: body. Any deviation
Smeltzer, S. et below normal may
al.2008. Brunner & indicate fluid retention
Suddarth’s Textbook
of Medical-Surgical
Nursing, ed 11. 2. Maintain vital -to obtain baseline
-monitor vital signs data that would
Philadelphia: signs within
Lippincott Williams & normal limits. reflect patient’s
Wilkins. condition

-Assess presence of -To be able to identify

edema that appropriate
potentiates fluid interventions to be
excess. done.

-Accurate I&O are

-Monitor intake and necessary for
output properly. determining renal
function and fluid
replacement needs.
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-Evaluate cognitive -Excess fluid volume

pattern. in the body may
cause an increase in
blood pressure. Due
to increase pressure
in the brain,
neurologic function
may be altered.

-Review laboratory -Laboratory results

data for sodium determine the level of
results and chest x- electrolytes in the
ray. body. Chest x-ray will
determine the
presence of fluid in
the lungs. Both these
tests will indicate
presence of fluid
retention in the body.

Collaborative:

-Restrict sodium and -Restricting sodium

fluid intake. and fluid intake will
help lower the
amount of fluid in the
body.

-Set an appropriate -Regulation of fluid

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rate of fluid infusion infusion will ensure

throughout the shift. appropriate amount
fluid given to the
client.

-Place in lateral -This is to reduce

position and change tissue pressure and
position every 2 risk of skin
hours. breakdown

-Medication will treat

-Administer underlying condition
medications that may have
caused excess fluid
volume in the body.
 126

NURSING CARE PLAN (2)

Intervention
Diagnosis Need Desired Outcome Intervention Rationale Evaluation Rationale
Modification
Ineffective tissue
Perfusion related to P After 8 hours of
decreased H nursing
hemoglobin Y intervention the
concentration S patient will be
I able to:
SUBJECTIVE CUES: O
L General:
“nipis na kaayo akung O Maintain effective
panit dali lang kaayu G tissue perfusion
masamad tapos dali I
lang pud kayo C
mabun’og” Independent:
N Specific:
E -establish rapport -to gain the patient’s Goal met, Continue Continuing
OBJECTIVE CUES: E -Identify factors trust and cooperation patient was nursing nursing
D that can able to intervention. interventio
>hemoglobin result of contribute to the verbalized n would
60g/L(normal 140- decreased understanding facilitate
180g/L) hemoglobin -to obtain baseline of present understand
-monitor vital signs
>capillary refill of concentration. data that would condition, ing of
greater than 4 sec. reflect patient’s “mao pud na factors that
>pallor condition ang gi ingon may
>blood pressure of sa aku ni worsen
90/60mmHg doctor” patient present
>spider angionoma -regulate IVF at desired verbalized. condition.
rate -to avoid deficit of
>weakness
fluid in the body
BACKGROUND
KNOWLEDGE: -morning care including
Decreased in oxygen oral care before and -oral care will
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resulting in the failure after meals remove food

to nourish the tissues particles between
at the capillary level. teeth and along
chewing surface;
client is prone to
sore and bad taste in
mouth which
contributes to
anorexia

-inspect for skin color -redness, heat,

and temperature tenderness and
changes, as well as localized edema are
edema. characteristics of
superficial
involvement.

-examine extremity for -distention of

obvious prominent superficial veins can
veins. Palpate gently occur in DVT
for local tissue tension because of backflow
through
communicating vein.

-assess for capillary -diminished capillary

refill refill usually present
in DVT.

-demonstrate -elevate legs when in -reduces tissue

tissue perfusion bed as indicated. swelling and rapidly
empties and
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superficial veins,
preventing over
distention and
thereby increasing
venous return

-instruct client to avoid -this activity

rubbing/massaging the potentiates risk of
affected extremity fragmenting/
dislodging thrombus
causing embolization
, and increasing risk
of complication.
Collaborative:

-Verbalized -apply warm, moist -maybe prescribe to

understanding of compresses or heat promote vasodilation
condition, therapy cradle to affected and venous return
regimen, side extremities if indicated and resolution of
effects of local edema.
medications.
-secure PRBC 3 units -to increase
of patients blood type hemoglobin of the
with TAPCOM patient.

-monitor laboratory Monitor anti

studies ( PT, PTT, coagulant therapy
aPTT) and presence of risk
factors; which
potentiate clot
formation.
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NURSING CARE PLAN (3)

Intervention
Diagnosis Need Desired Outcome Intervention Rationale Evaluation Rationale
Modification
Imbalance Nutrition: Within 8 hrs of
Less than body P appropriate
requirements related H nursing
to hepatic dysfunction Y intervention, the
S patient will be
I able to:
O
SUBJECTIVE CUES: L
“Namayat jud ko, wala O
naman gud ko gakaon G Gerenal:
ug kan-on Karun, I
dagahan pud bawala C Maintain balance
sa ako, ginagmay ra nutrition
pud akong kaon N
Karun”. E Independent
E Specific:
D
-Verbalize
OBJECTIVE CUES: understanding of -establish rapport -to gain the patient’s -goal met: Continue Continuity
the importance of trust and cooperation Patient is able to nursing of care to
 Weight Loss proper nutrition. enumerate foods intervention improve
-to obtain baseline that are restricted understan
 Poor skin -monitor vital signs data that would reflect as verbalized ding of the
turgor Fatigue patient’s condition “bawal jud ko importanc
maghkaon ug mga e of
 Temp: 36.5 -to avoid deficit of fluid
-regulate IVF at parat, tambok, nutrition in
in the body
desired rate tam-is na pagkaon. his
 PR: 70bpm
Bawal pud gani ko condition.
 RR: 24cpm ug gatas.”
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 BP: 90/60 -morning care -oral care will remove

including oral care food particles between
 Decrease before and after meals teeth and along
activity tolerance chewing surface;
client is prone to sore
and bad taste in
mouth which
BACKGROUND
contributes to
KNOWLEDGE:
anorexia
Adequate nutrition is
necessary to meet the -Able to Continuity
body’s demand. enumerate -determine ability to Goal met, patient Continue of care
minerals that are chew, swallow, taste, -to determine factors verbalized, “bawal nursing would
Nutritional status can that can affect
be affected by disease to be taken in dentures, lactose na dyud na ko intervention facilitate
moderate intolerance, pancreatic ingestion and/or magkaon ug mga and
or injury states (e.g digestion of nutrients
gastrointestinal amount. disorder parat, ug mga promote
malabsorption, karne nga taba relaxation
-discuss eating habits ingon ni doctor.” for
cancer, burns); including food
physical factors( e.g -to appeal to patient’s patient.
preference, like or dislikes
muscle weakness, intolerance/aversion
poor dentition, activity
intolerance, pain, -to determine factors
-determine that may affect food
substances abuse); psychological factors,
social factors(e.g lack choices
cultural or religious
of financial resources desires/influence
to obtain nutritious
foods) or -assess weight, age, -provides comparative
psychological body built, strength, baseline
factors(e.g trauma, activity/rest level
surgery, sepsis,
burns), adequate -Assist/ encourage
nutrition plays an silent to eat; explain -Improve nutrition/ diet
important role in reasons for the types is vital to recovery.
healing and recovery of diet. Feed client if Client may eat better if
period. Culture and tiring easily, or have family is involved and
 131

religious factors so/ significant others preferred foods are

strongly affects the assist client. Consider included as much as
food habits of patients. preference in food possible. Client and
Patients who are older intake. family must
experience problems understand protein
in forgetting to eat, intake limitations and
physical limitations how best to meet
that interfere with needs/ desired within
preparing food, limitation
deterioration of their
taste and smell,
reduction of gastric
secretion that -Encourage client to -Client may
accompanies aging eat all meals/ demonstrate loss of
and interferes with supplementary interest in food
digestion and social feedings because of nausea,
isolation and bore fatigue, generalized
dome that cause a weakness, malaise
lack of interest in
eating. This care plan
-Provide small -Poor tolerance to
addresses general
frequent meals larger meals may be
concern related to
nutritional deficit for due to increased
the hospital or home abdominal pressure
setting (ascites)

Reference:
-Limit high salt foods -Salt limitations can
Gulanick- help manage fluid
Meyer(Nursing Care complications in
Plan) cirrhosis

-Restrict intake of -aids in gastric

caffeine, gas irritation/ diarrhea and
 132

producing or spicy and abdominal discomfort

expressively hot or that may impair oral
cold foods intake/ digestion.

Continuity
-express feeling -Promote pleasant -promoting pleasant -goal met: Continue of care to
of comfort relaxing environment relaxing environment Patient was able to nursing prevent
will enhance food rest and reports no intervention more
intake pain. complicati
ons.
-Prevent or minimize -preventing minimized
unpleasant odors unpleasant odor will
lessen negative effect
on appetite or eating

-Provide assistance -conserving energy

with activities as reduces metabolic
needed. Promote demands on the liver
undisturbed rest and promote cellular
period, especially regeneration
before meals

-Educate patient to -this is to avoid

follow doctors diet complication cause by
prescription inappropriate amount
of minerals from food
intake

Dependent: -maintain nutrition and -goal met:

-Administer mange and treat his Due medications
medication condition--goal met, were given by the
due medications were NOD
given by the NOD