NURSING CARE PLAN

Name of Patient: Ms.HH Age: ___5 YRS OLD___ Ward: ___Pediatric Ward__

Chief Complaint: __UTI r/o DM1______Attending Physician: ___DR.G__

CUES NURSING DIAGNOSIS EXPECTED OUTCOME NURSING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE CUES: Acute Pain related to After 1 hour of nursing 1. Monitor urine color changes, Rationale: To identify After 1 hour of nursing
“Masakit po yung inflammation and intervention the client monitor the voiding pattern, the indications of duty the patient’s
tyan ko” as verbalized infection of the will report no or lessen input and output every 8 hours progress or deviations Pain is reduced
by the patient. pain on urination, no and monitor the results of the spasms can be
urethra, bladder and from expected results
pain in the suprapubic urinalysis repeated. controlled with pain
other urinary tract
OBJECTIVE CUES: region. scale of 3 out of 10
Pain Scale of 8 out of structures.
2. Note the location, time pain scale.
10 Rationale: To help
intensity scale (1-10) pain.
Facial Grimacing evaluate the place of
Guarding Behaviour obstruction and cause
Restless and pain
Irritability
3. Provide convenient Rationale: Increase
measures, such as massage. relaxation, reduce
muscle tension.

4. Give perineal care. Rational: To prevent

contamination of the
urethra.

Rationale: Relaxation,
5.. Divert attention to the fun.
avoid too feel the pain.

Rational: to control the

7. Collaboration of analgesics.
pain.
NURSING CARE PLAN
Name of Patient: Ms.AA Age: ___7 YRS OLD___ Ward: ___Pediatric Ward__

Chief Complaint: __R/I UTI (Urinary Tract Infection) Attending Physician: ___DR.G__

CUES NURSING EXPECTED NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OUTCOME

SUBJECTIVE Fever/Hyperthermia Client will 1. Identify assess causative contributing These factors can include excessive After 4 hours of
CUES: related to maintain body factors: heat production, such as occurs with nursing
“Nilalamig inflammation or temperature strenuous exercise, fever, shivering, interventions
ako.”as infection of 36.5 - 37.3 C Identify underlying cause. tremors, convulsions, hyperthyroid the Client body
verbalized by the Client body state, infection or use of temperature
patient. temperature sympathomimetic drugs, impaired reduced to 35.8
reduced to 37 heat dissipation and loss of degrees Celsius.
OBJECTIVE CUES: degrees thermoregulation. The patient
Skin warm to Celsius. and SO
touch responded to
Flushed skin Demonstrate 2. To evaluate effects or degree of Rectal and tympanic temperatures interventions
Temperature: behaviours to hyperthermia: most closely approximate core teaching and
38.7 degrees monitor and Monitor core temperature by appropriate temperature: however, abdominal actions
Celsius via axilla promote route. Note the presence of temperature core temperature monitoring may be performed.
normothermia. elevation. done in the premature neonate. Client Reported
comfort.
Client will be Monitor blood pressure and invasive Central hypertension or postural
comfortable hemodynamic parameters if available. hypotension can occur.

Monitor heart rate and rhythm. Dysrhythmias and electrocardiogram

(ECG) changes may eventually be
Monitor and record all sources of fluid loss such impaired by seizures or
as urine; hypermetabolic state (shock and
acidosis)

Oliguria and/or renal failure may occur

vomiting and diarrhea; wounds, fistulas; and due to hypotension, dehydration,
insensible losses. shock and tissue necrosis

Note the presence or absence sweating as the
body attempts to increase heat loss by
evaporation, conduction and diffusion.
Monitor laboratory studies such as arterial
blood gas, electrolytes and cardiac liver
enzymes.
3. To assist with the measures to reduce
body temperature or restore normal
body/organ function:
• Administer antipyretics, orally or
rectally as ordered. Refrain from use of aspirin
products in children or individuals with a
clotting disorder or receiving anticoagulant
therapy.
• Promote surface cooling by means of
undressing; cool environment and or fans;
tepid sponge baths or immersion or local ice
packs.
• Administer medications as ordered.
• Administer replacement fluids and
electrolytes
• Maintain bedrest
Can potentiate fluid and electrolyte
losses.
Evaporation is decreased by
environmental factors of high humidity
and high ambient temperature as well
as body factors producing loss of
ability to sweat or gland dysfunction
May reveal tissue generation,
myoglobinuria, proteinuria and
hemoglobinuria can occur as products
of tissue necrosis
May cause reye’s syndrome or liver
failure.
Alcohol sponge baths are
contraindicated because they increase
peripheral vascular constriction and
central nervous system depression;
cold water sponges or immersion can
increase shivering, producing heat.
To control shivering and seizures.
To support circulating volume and
tissue perfusion.
To meet increased metabolic
demands.
Fever may be treated at home to
relieve the general discomfort and
lethargy at home to relieve the general
4. To promote wellness:
• Instruct the parents and SO in how to
measure the patient’s temperature at what
body temperature to give antipyretic
medications, and what symptoms to report to
the physician.
5. Discuss the importance of of adequate
fluid intake.
discomfort and lethargy associated
with fever. Fever is reportable if it is
unresponsive to antipyretics and
fluids, because it often accompanies a
treatable infection.
To prevent dehydration.
NURSING CARE PLAN
Name of Patient: Ms.JR Age: ___17YRS OLD___ Ward: ___Pediatric Ward__

Chief Complaint: __ T/C ACUTE RENAL FAILURE,SEVERE ANEMIA______ Attending Physician: ___DR.G__

CUES NURSING DIAGNOSIS EXPECTED OUTCOME NURSING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE CUES: Activity intolerance At the end of 8 hours of Weigh regularly and evaluate weight Good intake is necessary for At the end of 8
“Nanghihina po yung related to general body nursing interventions, loss over time to determine degree of health and tissue repair hours of
katawan ko parang weakness the patient will be able malnutrition nursing
kulang yung lakas to: interventions,
ko.” As verbalized by Client will get enough the patient
the patient. rest and sleep Provide familiar and home cook foods Big meal will suppress the was able to:
appetite and small-frequent Respond to
OBJECTIVE CUES: Client will gain more meal are often better interventions,
Less movement energy tolerated teaching and
Droopy eyes actions
performed,
Give supplemental nutrition e.g., Client was
multivitamins able to rest
and gain more
energy.

Avoid unpleasant procedures to promote good appetite

immediately before and after meals
to prevent halitosis that may
Provide mouth care before meals aggravate loss of appetite

Provide clean and conducive To promote good appetite

environment during meal time to And improve the nutritional
improve appetite status.
NURSING CARE PLAN
Name of Patient: Ms.HH Age: ___5 YRS OLD___ Ward: ___Pediatric Ward__

Chief Complaint: __GENERALIZED BODY WEAKNESS T/C ACUTE LEUKEMIA______ Attending Physician: ___DR.L___

CUES NURSING EXPECTED NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OUTCOME

SUBJECTIVE CUES: Readiness for After 1 hour of Verify client’s level of understanding of Provides opportunity to EFFECTIVENESS: The
Enhanced Self- nursing therapeutic regimen. Note specific health goals. assure accuracy and nursing interventions
OBJECTIVE CUES: Care interventions the completeness of implemented are
The patient shows patient will be able knowledgebase for future effective since the
positivity towards the to: Identify steps necessary to reach desired health learning. goal was met as
treatment and goals. evidenced by the
Prevention of Disease Identify / use Understanding the client’s verbalization
Reoccurrence. additional process enhances of her needs to
resources as commitment and the comply with the
appropriate likelihood of achieving disease management
Accept client’s evaluation of own strengths / the goals.
Demonstrate limitations while working together to improve EFFICIENCY: The
proactive abilities Promotes sense of self- interventions done
management by esteem and confidence to are efficient since
anticipating and Acknowledge individual efforts/capabilities to continue efforts. they performed in the
planning for reinforce movement toward attainment best possible manner
eventualities of of desired outcomes. Provides positive with least waste of
condition/potential reinforcement time and effort;
complications Promote client/ caregiver choices and encouraging continued having and using
involvement in planning for implementing added progress toward desired requisite knowledge
Assume tasks/responsibilities. goals.
responsibility for The interventions are
managing Assist in implementing strategies for monitoring Promotes proactive sufficient to achieve
treatment progress / responses to therapeutic regimen. problem solving the goal.
regimen.
NURSING CARE PLAN
Name of Patient: Ms.AR Age: ___7 YRS OLD___ Ward: ___Pediatric Ward__

Chief Complaint: __T/C DENGUE FEVER Attending Physician: ___DR.G___

CUES NURSING DIAGNOSIS EXPECTED OUTCOME NURSING INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE CUES: Disturbed Sleeping After 8 hours of nursing Assess sleep pattern disturbances High percentage of sleep After 8 hours of
“Paputol-putolyung Patterns related to duty the patient will be that are associated with the disturbances can affect nursing intervention
tulog namin dito kasi interruptions for able to: environment. the recovery of the the patient was able
maya’t maya maya therapeutics, Demonstrate patient. To determine to display
may gigising at monitoring and other verbalization of feeling Observe and obtain feedbacks usual sleeping pattern and improvement in
magpapainum ng generated awakening rested. regarding on the usual sleeping to compare if there are sleeping pattern as
gamot.” As verbalized and excessive Decrease the presence of pattern, bedtime routine and the any improvements on the evidenced by:
by the patient’s S.O stimulation (noise and eyebags. usual number of hours of sleep sleeping pattern of the The patient
lighting). Have an Improvement of and rest. patient. To avoid verbalized: “Medyo
OBJECTIVE CUES: sleeping pattern. disturbances during sleep, nakatulog at sya
• Presence of eye Do as much care as possible and also to maximize the nakapagpahinga na
bags. Have Absence of without waking up the client and sleep and rest of the sya ng maayos
• Weakness and restlessness. do as much care as possible while client. For the patient to kumpara dati.” As
restlessness. the client is still awake. understand the stated by the patient’s
•Taking nap when importance of care being SO.
there is a chance or if Explain necessity of disturbances done to her and to
there is a free time. for monitoring Vital Signs and care minimize the complaints. The patient does not
•Yawning when hospitalized. look weak and
restlessness compare
to the past.
The presence of eye
bags has been
minimized or have
gone.
Decrease of the usual
yawning.
NURSING CARE PLAN
Name of Patient: Ms.JR Age: ___17 YRS OLD___ Ward: ___Pediatric Ward__

Chief Complaint: __T/C ACUTE RENAL FAILURE WITH SEVERE ANEMIA Attending Physician: ___DR.G__

CUES NURSING EXPECTED NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OUTCOME

SUBJECTIVE CUES: Fluid Volume After 8 hours of Assess patient’s condition For baseline data Goal met as
“Namamanas ang legs Excess nursing manifested by patient
at mukha ko , medyo related to intervention, the Record Intake and Output` Accurate I and O is necessary was able to
hirap din akong inability of patient shall for determining renal function and demonstrate
huminga.: as the kidneys demonstrate Restrict fluids fluid replacement needs and behaviors to monitor
verbalized by the to maintain behaviors to reducing risk of fluid overload fluid status and reduce
patient. body fluid monitor fluid status Weigh patient daily at the same time recurrence of fluid
balance. and reduce each day Fluid management is usually excess
OBJECTIVE CUES: recurrence of fluid calculated to prevent further fluid Stabilize fluid volume
Facial and legs edema excess Record occurrence of dyspnea retention AEB balance I & O,
normal VS, stable
> difficulty of Change position of client timely Daily body weight is best monitor of weight, and free from
breathing fluid status signs of edema
Note presence of edema
>shortness of breath To determine fluid retention
Evaluate mental status
>Vital Signs taken as To prevent pressure ulcers
follows: BP-90/60 Administer Diuretic as ordered
mmHg May indicate increase in fluid
T-37 P-81 R-26 Administer Antihypertensive as ordered retention

May indicate cerebral edema

To excrete excess fluids

To treat hypertension by
counteracting effects of decreased
renal blood flow