Nursing Care Plan

NURSING CARE PLAN

Date Assessment Need Nursing Diagnosis

Objective of Care

Nursing Intervention Evaluation

MAY

,2007

7am – 3pm

S/O: Watery,loose

stool(6x/day) in mod. amt

Vomited 5x/shift with sticky vomitus in scanty amount

Sunken fontanel noted

Sunken eyeballs noted

Dry lips & mucus membrane

Physiologic

Fluids & Electrolyte

s

Fluid volume deficit r/t severe dehydration to

consider electrolyte

imbalance 2˚ Acute

GastroenteritisRationale:

Acute Gastroenteritis

is an inflammation on the stomach &

GI tract which is manifested by

diarrhea, abdominal pain

Within 2 days of

providing nursing

care, will maintain fluid and

electrolytes volume at

a functional

level as evidenced

by:- will defecate semi-formed

Maintained accurate Intake and Output-patient may reduce fluid intake during periods of crisis because of malaise, anorexia,and so on.

Monitored v/s,comparing with patient’s normal/ previous readings

- reduction of circulating blood volume can occur from ↑fluid loss resulting in hypotension and tachycardia

Observed for fever, changes in LOC,skin

After 8 hrs of nursing care,GOAL PARTIALLY MET

Patient regained and maintained fluid volume at a functional level as evidenced by:BP=110/70mmHgPR=96bpmUrine Output= 30cc/hr

noted. Distended

abdomen noted

Poor sucking noted

Delayed capillary refill noted

Pale skin Wt=5.2kgs. FFP @ 78ccx

4 hrs x 3 cycles. With serial # 111-06-13473 type B+

Serum Na=130.4mEq

Serum Ca= 0.84mEq

Serum K=3.15 mEq

associated with nausea,

vomiting, fever, and abdominal

distention& excessive

elimination of waste caused

electrolyte imbalance

Reference: Medical Surgical Nsg. 10th Ed by Brunners & Suddarth

stool at lest 2 times a day- there will be decrease occurrence of vomiting at least 12 times a day- will manifest moist lips and mucous membranes and capillary refill in 2-3 seconds- weight of 5.2 kgs will

turgor, dryness of skin and mucous membranes, pain.

- symptoms reflective of DHN/ hemoconcentration with consequent vasoocclusive state.

Monitored v/s closely during blood transfusions and noted presence of dyspnea, crackles,ronchi,wheezes, diminished breath sounds cough and cyanosis.

- patient’s heart may be already weakened and prone to failure due to chronic demands,placed on it by the anemic state.

increase to 5.7 kgs- fever will subside with the temperature of less than 37.5

Heart may be unable to tolerate the added fluid volume from the transfusions or rapid IV fluid administered to heart crisis/shock

•Administered fluids as indicated- replaces losses/deficits. Fluids must be given immediately to decrease hemoconcentration and prevent further interaction


Objective of Care


AP

Subjective:“Dili man ko ganahan

Activity Intolerance r/t

Within 8 hrs of

Assessed the degree of dehydration.- to provide baseline

After 2 days of providing nursing care,

RIL30,2007

3 – 11pm

mulihok ky dali ra man ko kapuyon”, as verbalized.Objective:

Pale lips Tachycardia

(PR=101bpm) O2 inhalation

@ 5L/min via nasal cannula

Weakness, body malaise,fatigue

Hemoglobin Mass Concentration= 20.

BP=80/60mmHg

RR=28cpm

Safety &

Security

EnergyMgt.

imbalance between O2

supply and demand 2˚

Hypovolemic shock

Rationale:Hypovolemic shock results from loss of fluids & occurs more rapidly than fluid intake which results to the imbalance of O2 supply and demand to the body. This oftenly causes fatigue 7 weakness which can

nurse-patient

interaction, will

demonstrate a ↓ in

physiologic signs of

intolerance as

evidenced by:

-PR,RR, & BP will remain within normal ranges-decrease in fatigue-increase ability to

information. Established a 24 hour

fluids and electrolytes replacement needs and routes (IV,PO) to be used.

- prevents peak/valleys in fluid level.

Administered IV fluids as indicated and regulated well at prescribed rate.

- to correct fluid losses. Administered one unit

fresh frozen plasma. - to replace electrolyte losses.• provided nutritious diet via NGT. - to meet the body’s nutrient requirements.• administered anti- infective as ordered by

GOAL PARTIALLY METAs evidenced by:

- defecated semi-solid stools at lest 2 times a day - vomited at least twice a day. - manifested moist lips and mucous membranes and capillary refill of at least 2-3 seconds.. - weight increased to 5.5 kgs from 5.2 kgs - fever subsided with a temperature of

interfere with the individual’s ability to work.Reference: Medical Surgical Nsg. 10th Ed by Brunners & Suddarth

participate in activities, such as personal hygiene & nail care.

the physician. - prevents the spread of enteropathogenEncougaged to properly sterilize water.-inhibits the growth of microorganism.Monitored the I & O, and weight everyday.

- to assess the fluid level. Administered Paracetamol for fever as ordered. - to lower down doy temperature to normal range.Instructed watcher to perform TSB. - provide comfort an lowered body temperature.


Objective of Care


APRIL30,2007

3 – 11pm

Risk Factors: Decreased

hemoglobin (20gm/dL)

Invasive procedures such as foley catheter insertion, blood transfusion, and starting double IV lines

Objective: Febrile @

37.8˚C Not taken a

bath for 2 days

Safety &

Security

InfectionProtection

Risk for Infection r/t inadequate secondary

defenses 2˚ Aplastic Anemia

Rationale:Aplastic anemia makes one susceptible to complications on RBCs, WBCs & platelets which gives high risk for infection.

Within 8 hrs of nurse-patient

interaction, will

participate on

interventions to prevent/ reduce risk of infection

as evidenced by:

- Body temperature will be within normal

Washed hands before & after each care activity , even if sterile gloves were used-Reduces risk of cross - contamination

Inspected wounds/site of invasive devices daily, paying particular attention to parenteral nutrition lines. Noted signs of local inflammation/infection.

- May provide portal of entry for infection, primary infecting organisms,as well as early identification of secondary infections.

Noted signs and

After 8 hrs of nursing care,GOAL MET

Patient was able to identify interventions to prevent or reduce risk of infection as evidenced by:-Body temperature down to 37˚C-“kinahanglan jud d I na limpyo pirmi atong lawas”, as verbalized.

Untrimmed fingernails

WBC, in particular, fights against foreign substances that enters the body.

Reference: Medical Surgical Nsg. 10th Ed by Brunners & Suddarth

ranges-verbalization of understanding on proper hygiene

symptoms of sepsis (systemic infection): fever, altered LOC.

-To assess causative/ contributing factors

Monitored temperature trends.

-fever (38.5ºC - 40˚C) is the result of endotoxin effect on the hypothalamus and pyrogen-released endorphins•Instructed and educated to participate in hygienic care- facilitate in promoting personal wellness

NURSING MANAGEMENTa. Nursing Care Plan

Ineffective Tissue Perfusion related to decrease in hemoglobin countCUES NURSING

DIAGNOSISSCIENTIFIC EXPLANATION

OBJECTIVE NURSING INTERVENTION

RATIONALE DESIRED OUTCOME

S = Ø

O = the patient manifested:

- Low hgb count (56)

- Low hematocrit count ( .17)

- Paleness- Pale

Palpebral

Ineffective tissue perfusion related to decrease in hemoglobin count (56)

Acute glomerulonephritis is an inflammation of the glomerular capillaries. Because of this inflammation the blood vessels, the kidney cannot adequately produce erythropoietin that leads

Short term:After 4 hrs of nursing interventions the patient will be able to verbalize understanding of condition and therapy regimen

Long Term:

- Establish rapport

- Monitor and record VS

-Assess pt. gen. condition

-Encourage quiet, restful

-To gain trust and cooperation

-To have a baseline data

-To have baseline data and note any abnormal findings

-To

Short term:The patient shall have verbalized understanding of condition and therapy regimen after 4 hours of nursing interventions

Long Term:The patient shall have demonstrated increased perfusion as individually appropriate after 5 days of nursing interventions

conjunctiva

- Body weakness

- Restlessness

- Cold and clammy skin

The patient may manifest

- Bronchospasm

- Dysrhythmias

- Capillary refill longer than 3 secs

- Use of accessor

to decrease in hgb and hct count, thus resulting to anemia. Because of this, the patient manifested pale palpebral conjunctiva and paleness. Then the oxygen being supplied in the body is not enough due to decrease production of RBC by the kidney

After 5 days of nursing interventions the patient will be able to demonstrate increased perfusion as individually appropriate

atmosphere

-Encourage early ambulation once tolerated

-Discourage sitting/standing for long periods, wearing constrictive clothing, crossing legs

- Check for calf tenderness

conserve energy/lower tissue oxygen demands

-To enhance venous return

-To improve and facilitates good circulation

-May indicate thrombus

y muscle in breathing

- Nasal flaring

which are responsible for the oxygenation of tissues thus leading to ineffective tissue perfusion.

- Elevate head of bed especially at night

-Instruct to avoid strenuous activity

- Restrict sodium, fluid and fat intake as indicated

- Instruct patient’s SO about food rich in iron

-Regulate

formation

-To increase gravitational blood flow

-To conserve energy

-To decrease excess fluid volume

-To increase hgb count

IVFAs ordered

-Promote adequate bed rest

- Attend needs

-Administer meds as ordered

-To maintain hydration

-To promote wellness

-To promote health

-To promote recovery

Activity Intolerance related to muscle weakness

ASSESSMENT

NURSING

DIAGNOSIS

SCIENTIFIC EXPLANATION

OBJECTIVES

INTERVENTION

RATIONALE EXPECTED OUTCOME

S = Ø

O = Patient manifested the following:

- body weakness

- restlessness

- physical inactivity


Activity Intolerance related to muscle weakness aeb physical inactivity, Low hgb count (56)Low hematocrit count ( .17)Pale

Activity intolerance is insufficient physiological or psychological energy to endure or complete required or desired daily activities. This is present for patient with AGN because patient with such condition can have decrease erythropoietin

Short Term: After 4 hours of nursing interventions, the patient will be able to verbalize understanding of the causative factors and necessary interventions.

Long Term:

-Establish rapport

-Monitor and record VS

-Note patient’s report of weakness, fatigue and pain

-Identify activity needs or desired

- To obtain patient’s cooperation

- To obtain baseline data

-To identify contributing factors

-To know the appropriate activity level

- To prevent

Short Term: The patient shall have verbalized understanding of the causative factors and necessary interventions after 4 hours of nursing interventions.

Long Term: The patient shall have reported measurable increase in activity tolerance after 3 days of nursing interventions.


- Pale palpebral conjunctiva

- paleness

Patient may manifest the following:

- Dizziness

- Vertigo- Confusi

on- Altered

mental

palpebral conjunctivapaleness

production since the glomerular tissues are inflammed. With this condition, the patient can have decrease level of hgb and hct. And since hgb is responsible for oxygenation of tissue, there will be decrease oxygen being delivered to the tissues of the body. As a compensatory mechanism, the body will increase demand of

After 3 days of nursing interventions, the patient will be able to report measurable increase in activity tolerance.

-Adjust activities

-Plan care with rest periods between activities

-Provide positive atmosphere, while acknowledging difficulty of the situation for the client

-Promote comfort measures for relief

overexertion

-To reduce fatigue

- Helps to minimize frustration re-channel energy

- To enhance ability to participate in activities

- To sustain motivation

status- Poor

muscle tone

oxygen by increasing the respiratory rate of the patient which results to fatigue. Because of this, there will be faster consumption of ATP leading to weaker contractions thus causing muscle weakness. And if the patient has muscle weakness, there will be activity intolerance.

from pain

-Give patient information that provides evidence of daily progress

-Assist patient to learn and demonstrate appropriate safety measures

-Encourage client to maintain positive attitude

-To prevent injuries

- To enhance sense of well-being

Fatigue related to physiological factor:anemia

ASSESSMENT

NURSING

DIAGNOSIS

SCIENTIFIC EXPLANATIO

NOBJECTIVE

SINTERVENTI

ONRATIONALE

EXPECTED OUTCOME

S = Ø

O = the patient manifested the following:

- body weakness

- restlessn

Fatigue r/t

physiological

factor:anemia 2°

to disease conditio

n

AGN is an inflammation of glomerular capillaries. Because of the inflammation, the function of the kidney for

Short Term: After 4 hours of nursing interventions, the patient will be able to identify basis of fatigue

Establish rapport

Monitor and record VS

Identify presence of physical and/or psychologic

- To gain patient’s trust and cooperation

- To obtain baseline data

- To assess causative or contributing factor

Short term: The patient shall have identified basis of fatigue and individual areas of control after 4 hours of nursing interventions.

Long Term: The patient shall have performed ADLs at level of ability After 1 week of nursing interventions.

ess- physical

inactivity



- Pale palpebral conjunctiva

- paleness

Patient may Manifest:

- dizziness-confusion- poor muscle

erythropoiesis is affected which results in decrease RBC production leading to anemia. The body now will have decrease hgb and hct level. And since hgb is responsible for oxygenation of tissue, there will be less oxygen supply to tissues of the body. The body

and individual areas of control

Long Term: After 1 week of nursing interventions, the patient will be able to perform ADLs at level of ability.

al disease states

Determine ability to participate in activities/level of mobility

Note daily energy patterns

Establish realistic goals with patient

Plan care to allow individually adequate

- To assess degree of fatigue

- Helpful in determining pattern or timing of activity

- Enhances commitment to promoting optimal outcomes

- To provide rest periods

tone- vertigo-altered mental status

then will compensate by increasing the respiratory rate of the patient which may lead to fatigue.

rest periods

Schedule activities for periods when patient has the most energy

Provide environment conducive to relief of fatigue

Assist with self care needs and ambulation as indicated

Promote quiet and

To maximize participation

- Temperature and level of humidity are known to affect exhaustion

-To help patient to cope with fatigue

-To provide comfort

-To promote

relaxing environment

Encourage early ambulation once tolerated

Avoid over stimulation/ under stimulation

Discuss routines

Instruct in stress management skills of relaxation

venous return and gradually increased patients ADL

- Impaired concentration can limit ability to block competing stimuli

- To promote sleep

- To assist patient to cope with fatigue

-To conserve energy

Instruct to avoid strenuous activity

Instruct to eat nutritious foods and foods rich in iron

Refer to physical or therapy as appropriate

-to maintain weight and appropriate nutrition

- To maintain strength and muscle tone and to enhance sense of well-being

Fluid volume excess r/t disruption of regulatory mechanism AEB by facial edema

ASSESSMENT

NURSING DIAGNOSIS


OBJECTIVES INTERVENTION

RATIONALE

EXPECTED OUTCOME

S= ØO= patient manifest

Fluid volume excess r/t disruption of regulatory

Acute glomerulonephritis is an inflammation of

Short term:After 4º of nursing

- Establish rapport

- To gain the trust of the client

Short term:The pt shall have verbalized understanding of individual fluid

ed:

- facial edema c puffy eyelids

- body malaise

- cold and clammy skin

- restlessness


- Low hematocrit count( .17)

- Albumin: +1

mechanism AEB by facial edema2° disease condition

the glomeruli of the kidney. Children above 2y/o are at risk to have AGN caused mostly by an antrapment and collection of antigen-antibody complexes in the glomerular capillary membrane. The inflammation causes damage to the kidney, thus altering the glomerular filtration rate that will eventually lead to excretion of albumin. With decreased albumin level

interventions the pt will be able to verbalize understanding of individual fluid restrictions

Long term:After 5 days of nursing interventions the pt. will be able to demonstrate reduction of the recurrence of fluid

- Monitor VS andnote level of consciousness

-Monitor I & O

-Evaluate pt. mental status

_Provide quite

- To have a baseline data and to reveal alteration

- To reveal alteration in fluid status -To assess for the presence of confusion, personality changes and to

restrictions after 4 hours of nursing interventions

Long term:Pt. shall have demonstrated reduction of the recurrence of fluid excess after 5 days of nursing interventions

The patient may manifest:

- Changes in mental status

- Generalize edema

- Dyspnea

- Changes in respiratory pattern

- Jugular vein distent

will result to decrease colloidal oncotic pressure and will lead to shifting of fluid from intracellular to interstitial spaces causing the pt. to have edematous face, decrease hct, and hgb, and cold and clammy skin. because of this there is stasis of fluid, confirming the nursing diagnosis of excess fluid volume.

excess environment

-Encourage frequent change in position

-Measure abdominal girth

- Restrict fluid/sodium intake as indicated

-

check for cerebral edema

_to promote wellness

-To reduce/prevent tissue pressure and risk of skin breaksdown

-To assess for increasing fluid and edema

ion Administer diuretics as ordered

-To reduce further edema

-To promote fluid excretion

Self-care deficit related to weakness

ASSESSMENT

NURSING DIAGNOSIS


OBJECTIVES INTERVENTION

RATIONALE

EXPECTED OUTCOME

S= Ø

O= The Patient manifested:

-body weakness-pale palpebral conjunctiva-pale nailbeds -low hemoglobin count (56) -tachycardia-unkempt hair-

Self-care deficit related to weakness AEB unkempt hairuntrimmed dirty toenails and fingernails

Because of impaired renal function, the kidneys can not produce erythropoietin, a substance necessary for hematopoiesis or RBC production. This event leads to anemia as evidenced by low level of hemoglobin which is primarily responsible for the transport of oxygen to the body. The patient is deprived of enough tissue oxygenation as hemoglobin

SHORT TERM:After 3º of nursing intervention, the pt will be able to identify individual areas of weakness and needs for self-care.

LONG TERM:After 2 days of nursing intervention, the pt will perform self-care

-Establish rapport

-Determine current capabilities and barriers to participate in self-care

-Identify reasons for difficulty in self-care

-To gain the trust of the client

-Comprehensive functional assessment included independent performance of basic ADL’s, social activities, sensory abilities and ability to ambulate

-Underlying cause

SHORT TERM:The pt shall have identified individual areas of weakness and needs for self-care, After 3º of nursing intervention

LONG TERM:The pt shall have performed self-care activities within the level of own ability, After 2 days of nursing intervention

untrimmed dirty toenails and fingernails


- Low hematocrit count( .17)

The patient may manifest:

-dizziness-drowsine

drops to normal level. This may cause the patient to have pale palpebral conjunctiva and nail beds, tachycardia, dizziness, lethargy, drowsiness and muscular weakness. The patient’s energy reserve is depleted and experiences weakness. Because of such, the patient is not able to perform self-care activities like maintaining appearance at a satisfactory level

activities within the level of own ability.

-Determine hygiene needs and provide assistance as needed with activities including care of hair, nails, skin and brushing of teeth

-Determine individual strength and skills of patient

affects choice of intervention or strategies and problem may be minimized

-Meets the needs while supporting patient participation

-Prepares for

ss-lethargy

as evidenced by unkempt hair and as well as poor personal hygiene as evidenced by untrimmed and dirty toenails and fingernails.

-Involve patient in formulation of plan of care at level of ability

-Promote patient/SO participation in problem identification and decision making

-Encourage energy –saving techniques

increased independence which enhance self-esteem

-Enhances sense of control and aids in cooperation and mainte-nance of independence

-Enhances commitment to the plan and optimizes outcome

-Shampoo or style hair as needed and provide or assist with manicure

-Encourage or assist in routine mouth and teeth care daily

-Encourage food and fluid choices

-Conserves energy, reduces fatigue and enhances pt’s ability to perform tasks

-Aids in maintaining appearance

-Reduces risk of gum disease/ tooth loss and enhances

reflecting individual likes especially those rich in iron and vitamin C

oral health

-To meet nutritional demands

Documents

Nursing Care Plan