IX.

Prioritized Nursing
Care Plans

36
Name of Patient: Cardo Dalisay

Diagnosis: Toxic Goiter and Diabetes Mellitus

1st Priority: Imbalance Nutrition less than body requirements related to inability to ingets adequate amounts of food.

2nd Priority: Activity Intolerance related to imposed activity restriction.

3rd Priority: Deficient Knowledge related to misinterpretation of information.

4th Priority: Risk for Infection related to chronic illness.

5th Priority: Readiness for Enhanced Therapeutic Regimen Management

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 1st Priority
Table IX.1
Assessment Nursing Diagnosis Objectives Intervention Rationale Evaluation
Subjective: Imbalance Nutrition Short term goal: Dependent: Subjective:
less than body
Niniwang ko maam requirments related At the end of 2 Taken a Family members Niniwang ko maam
sukad atong pagkabalo to Inability to ingest hours of nursing nutritional history may provide sukad atong
nako nga naay koy adequate amounts of Intervention the with the more accurate pagkabalo nako nga
sakit nga diabetes, food as evidenced by patient will be able to participation of details on the naay koy sakit nga
goiter ug Tb as weight loss vebalize significant others. patients eating diabetes, goiter ug
verbalized by the understanding of habits, especially Tb as verbalized by
patient. significance of if patient has the patient.
nutrition to healing altered
Objective: process and general perception. Objective:
health. Looked for The patient
Weight loss physical signs of encountering -Weight loss from 77
from 77 kg to poor nutritional nutritional kg to 54kg
54kg intake. deficiencies may - Documented
Documented Long term goal: resemble to be inadequate caloric
inadequate sluggish and intake
caloric intake At the end of 4 fatigued. - Loss of
Dysphagia months of nursing subcutaneous tissue

38
 Poor muscle intervention the Ascertained Body mass index - Poor muscle tone
tone patient will be able to healthy body (BMI) is a - Weight 10% to 20%
Thin for age : weight for age measure of body below ideal body
Inadequate -Patient weighs and height. fat based on your weight and height
energy sources within 10% of ideal Compute the weight in relation -Inadequate energy
body weight (IBW). Body mass index to your height, sources
-Patient displays of the client. and applies to
nutritional ingestion most adult men
sufficient to meet and women aged
metabolic needs as Independent: 20 and over.
manifested by stable Meal planning is
weight Teach the patient an important tool
-Patient takes how to make to manifest the
adequate amount of Meal planning nutritional
calories or nutrients. approproate for standards for
the nutritonal every food intake
needs of the of the patient
patient. This means
Encouraged to eating a wide
eat well with variety of foods in
balaced diet of the right

39
 carbohydrates, proportions, and
Proteins and fat. consuming the
right amount of
food and drink to
achieve and
maintain a
healthy body
weight.
Consider six Eating small,
small nutrient- frequent meals
dense meals lessens the
instead of three feeling of fullness
larger meals daily and decreases
to lessen the the stimulus to
feeling of vomit.
fullness.
Weighing is an
Weigh the patient assessment tool
as indicated to determine the
adequacy of
nutritional intake

40
 .
This it to provide
Encourage to proper hydration
drink sufficient to the body.
amount of fluids.
Drink 8-10
glasses a day.

41
Table IX.2 2nd Priority
Assessment Nursing Diagnosis Objectives Intervention Rationale Evaluation
Subjective: Activity Intolerance Short term goal: Dependent: Short term
related to Imposed evaluation:
Mag lisod ko ginhawa activity restriction At the end of 2 Established Motivation and
kung mag sige ko ug hours of nursing guidelines and cooperation are At the end of 2
lihok2x nga hago kaayo. intervention the goals of activity enhanced if the hours the patient
- As verbalized by patient will be able with the patient patient identified methods to
patient. to identify methods and/or SO. participates in reduce activivty
to reduce activity goal setting. inlerance and
Objective: intolerance and Observed and Sleep deprivation verbalized
verbalize and use monitored the and difficulties conservation
Inadequate energy-conservation patients sleep during sleep can techniques.
energy sources techniques. pattern and affect the activity Goals met.
Deconditioned the amount of level of the patient Long term
state sleep achieved these needs to evaluation:
exertional over the past be addressed
discomfort or Long term goal: few days. before successful At the end of 4
dyspnea At the end of 4 activity months of nursing

42
 RR=30cpm months of nursing progression can intervention the
HR=110bpm Intervention the be achieved. patient
-verbal report of fatigue patient will be able Assisted with Assisting the Exhibited tolerance
or weakness to: ADLs while patient with ADLs during physical
Limited carrying -Exhibit tolerance avoiding patient allows activity as evidenced
of objects during physical dependency conservation of by a normal
Insufficient activity as evidenced energy. Carefully fluctuation of vital
muscle tone by a normal balance provision signs during physical
fluctuation of vital of activity.
signs during physical assistance; facilita
activity. ting progressive
endurance will
ultimately
enhance the
patients activity
tolerance and
self-esteem.
Independent:

Assessed the Provides baseline

physical activity information for

43
 level and formulating
mobility of the nursing goals
patient during goal
. setting.
Adequate energy
Assessed the reserves are
patients needed
nutritional during activity.
status. Fatigue can limit
the patients
Determined the ability to perform
patients daily needed activity. It
routine and can also be a
over-the-counter medication side
medication. effect. Pay
attention to the
patients use of
beta-blockers,
calcium channel
blockers,
tranquilizers,

44
 antihistamines,
relaxants, alcohol,
and sedatives.
Taught energy These techniques
conservation reduce oxygen
techniques, consumption,
such as: allowing a more
Sitting to do prolonged activity.
tasks
Pushing rather
than pulling
Sliding rather
than lifting
Working at an
even pace
Resting for at
least 1 hour
after meals
before starting
a new activity.

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 Table IX.3 3rd Priority
Assessment Nursing Diagnosis Objectives Intervention Rationale Evaluation
Subjective: Short Term: Dependent: Short Term:
Deficient Knowledge
Wala na jud ko related to At the end of Provided mutual This clarifies the At the end of the
kasabot sa akong misinterpretation of the 2-hour goal setting with expectations of nurse 2-hour intervention,
sakit. Musamot information intervention, the the patient. and client. the client was able
akong sakit kung client will be able to Let the patient This can arouse to participate in
mag inom ko daghan participate in shared about interest or sense of learning process,
tambal. learning process, what he knows being overwhelmed. exhibited increase
- As verbalized exhibit increase and move to interest and
by patient interest and assume what he doesnt assumed
responsibility for own know, responsibility for
learning by asking progressing from own learning. Goals
questions and simple to met.
verbalize complex.
Objective: understanding of
condition, disease Independent: Long Term:
Agitated process and At the end of 4
Verbalizing treatment. Identified Motivation may be months, the client
inaccurate motivating positive or negative was able to initiate

46
 information Long Term: factors for the feedback. necessary lifestyle
Exaggerated individual. changes and
Conclusion At the end of 4 Provided To prevent overload. participated in
months, the client information treatment regimen.
will be able to relevant to
identify relationship clients
of signs and condition.
symptoms to the Provided This could encourage
disease process and positive continuation of
correlate symptoms reinforcement. efforts.
with causative Stated To meet learners
factors and initiate objectives needs.
necessary lifestyle clearly in the
changes and clients terms.
participate in Provided an This promotes a
treatment regimen. active role for sense of control over
the client in the situation and is a
the learning means for
process. assimilation and
using new
information.

47
 Provided To answer questions
access and validate
information for information while in
the contact distance.
person.

48
Table IX.4 4th Priority
Assessment Nursing Diagnosis Objectives Intervention Rationale Evaluation
Short Term: Dependent: Short Term:
Not applicable for Risk for Infection
Risk diagnosis. related to chronic At the end of Identified For lifestyle At the end of the
illness. the 2-hour resources modification. 2-hour intervention,
intervention, the available to the client was able
client will be able to individual. to verbalized
verbalize understanding of
understanding of Referred to the For medical individual causative
individual causative health center for treatment regimen. factor and identified
factors and identify effective health interventions to
interventions to maintenance. prevent or reduce
prevent or reduce risk of infection.
risk of infection.
Long Term:
Long Term: Independent: At the end of 4
Assessed for These are factors months, the client
At the end of 4 age, presence that are at risk for was able to
months, the client of underlying infection. demonstrate
will be able to disease, techniques and

49
demonstrate lifestyle and lifestyle changes to
techniques and nutritional promote safe
lifestyle changes to status. environment.
promote safe Provided To increase
environment. information and awareness and
encouraged the prevention of
client in disease.
appropriate
community
programs.
Reviewed To assess for
clients wellness.
nutritional
needs.

Encouraged To avoid bladder

client to distension and
maintain urinary stasis.
adequate
hydration.

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 Table IX.5
5th Priority
Assessment Nursing Diagnosis Objectives Intervention Rationale Evaluation
Subjective: Readiness for Short Term: Dependent: Short Term:
enhanced
Mag tumar na Therapeutic At the end of Identified additional Provides further At the end of the
man jud kog Regimen the 2-hour community opportunities for 2-hour intervention,
tambal, padayon Management intervention, the resources groups. anticipatory the client was able
lang gyapon ko sa client will be able to problem solving. to assume
akong insulin plant. assume Independent: responsibility for
- As responsibility for managing treatment
verbalized managing treatment Verified clients Provides regimen and
by patient regimen and identify level of opportunity to identified use of
use of additional knowledge of assure accuracy additional
resources as therapeutic and completeness resources.
appropriate. regimen. of knowledge base
Objective: for future learning.
Active Long Term: Discussed To note whether Long Term:
participation to At the end of 4 present resources changes can be
teachings months, the client used by client. arranged. At the end of 4
will be able to Assisted in Promotes proactive months, the client
No unexpected demonstrate implementing problem solving. was able to

51
acceleration of proactive strategies for demonstrate
illness management by monitoring proactive
symptoms anticipating and responses to management by
planning for therapeutic anticipating and
eventualities of regimen. planning for
condition for Accepted clients Promotes sense of eventualities of
potential evaluation of own self-esteem and condition for
complications and strengths while confidence to potential
remain free of working together continue efforts. complications and
progression of to improve remained free of
illness. abilities. progression of
illness,

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