B.

NURSING CARE PLAN

1. NURSING CARE PLAN FOR ACUTE PAIN

CUES NURSING SCIENTIFIC OBEJECTIVE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
Subjective: Acute Pain In the past, pain LONG TERM: INDEPENDENT: The client’s
r/t surgical control was a pain has been
The client incision major problem After the 1. Assess vital 1. Changes reduced to
verbalized,” Ang after cesarean nursing signs. in these vital pain scale of 2.
masakit lang sa birth. Pain was intervention, signs often
akin ngayon ay so intense from the client will 2. Encourage indicate
yung tahi ko.” the uterine or be able to verbalization of acute pain
abdominal have a feelings about and
Objective: incision that it reduced pain the pain. discomfort.
interfered with a in the pain
 Patient’s woman’s ability scale of 2. 3. Provide
pain scale to move and additional
score is 4 deep breathe. SHORT comfort
(Moderate TERM: measures; e.g. 3. Improves
Pain) (Source: back rub, heat/ circulation,
 Facial Maternal and After the cold reduces
grimace Child Health nursing applications. muscle
Nursing by intervention tension and
Adelle Pillitteri) the client will anxiety
be able to associated
apply nursing with pain.
intervention 4. Encourage Enhances
intended to use of relaxation sense of well-
improve techniques; e.g. being.
condtion. deep breathing
exercises. 4. Relieves
muscle and
emotional
5. Encourage tension
adequate rest enhances
periods. sense of
control and
DEPENDENT: may improve
coping
6. Administer abilities.
analgesics as
indicated to 5. To prevent
maximal dosage fatigue.
as needed.

7. Provide
around the clock
analgesia with 6. To
intermittent maintain
rescue doses. “acceptable”
level of pain.

7. Research
supports
need to
administer
analgesics
around the
clock initially
to prevent
 rather than
merely threat
pain.

2. NURSING CARE PLAN FOR HYPERTHERMIA

CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATIO

DIAGNOSIS EXPLANATIO S S N
N
Subjective: Hyperthermi In a fever, the LONG INDEPENDENT: The client
a r/t Trauma set point of the TERM: 1. Monitor the was able to
The client hypothalamic client’s 1. The temperature maintain core
verbalized, thermostat After the temperature. of 102°F-106°F temperature
“Mainit ang changes nursing Note shaking (38.9°C-41.1°C) within normal
pakiramdam ko.” suddenly from intervention chills/profuse suggests acute range after
the normal the client will diaphoresis. infectious disease the nursing
Objective: level to a be able to process. Fever interventions.
higher value as maintain core pattern may aid in
 Warm to a result of the temperature diagnosis; eg.
 touch effects of within normal sustained or
 Flushed tissue range. continuous fever
skin destruction, curves lasting
pyrogenic SHORT more than 24
Measurement: substances, or TERM: hours suggest
dehydration on pneumoccocal
T 38° C the After the pneumonia, scarlet
hypothalamus. nursing of typhoid fever;
intervention remittent fever
(Source: the client will (varying only a few
Fundamentals be able to degress in either
of Nursing 7th apply the direction) reflects
Edition, by interventions pulmonary
Kozier, page intended to infections;
488) improve intermittent curves
condition. or fever that
returns to normal
once in 24 hour
period suggests
septic episode,
septic endocarditis
 or tuberculosis
(TB). Chills often
precede
temperature
2. Monitor spikes.
environmental
temperature, 2. Room
limit/add bed temperature/numb
lines as er of blankets
indicated. should be altered
to maintain near-
normal body
temperature.
3. Provide tepid
sponge baths, 3. May help reduce
avoid use of fever.
alcohol.

DEPENDENT:

4. Administer
 antipyretics. 4. Used to reduce
fever by its central
axon on the
hypothalamus;
fever should be
controlled in clients
who are
nuerotropenic or
asplenic.
However, fever
may be beneficial
in limiting growth of
organisms or
enhancing
autodestruction of
infected cells.

3. NURSING CARE PROCESS FOR DISTURBED BODY IMAGE

CUES NURSING SCIENTIFIC OBJECTIV INTERVENTIO RATIONALE EVALUATIO
DIAGNOSI EXPLANATIO E N N
S N
LONG INDEPENDENT The client was
Subjective: Disturbed If we examine TERM: : able to
Body Image our lives as 1. A change in recognize &
As verbalized by the r/t women, we can After the 1. Discuss function may incorporate
client, “ feeling ko ang Pregnancy see several nursing meaning of be more changes into
taba-taba ko.” patterns of intervention, change to client. difficult for self-concept
emotional the client some to deal without
crises. All the will be able with than a negating self-
Objective: periods---the to recognize change in esteem.
appearance of & appearance.
 verbalization of menarche, incorporate 2. Have client
negative pregnancy, & changes describe self, 2. To develop
feelings about postpartum into self- noting what is new &
one’s self. recovery & concept positive & what creative
menopause--- without is negative. solutions.
are marked by negating
extraordinary self-esteem. 3. Listen to
changes in client without
body image. SHORT comments & 3. Different
These TERM: responses to situations are
significant After the the situation. upsetting to
changes in the nursing different
body are intervention, people,
almost always the client 4. Visit client depending on
accompanied will be able frequently & individual
by to apply the acknowledge coping skills &
corresponding intervention the individual as past
emotional intended to someone who is experiences.
changes. improve worthwhile.
condition. 4. Provides
(Source: “The opportunities
complete 5. Make time to for listening to
postpartum sit down & concerns &
guide.” talk/listen to questions.
p.43 client while in
By: Diane the room.
Lynch-Fraser.) 5. To
6. Help client to decrease
select & use sense of
clothing & isolation or
make-up. loneliness.

7. Refer to
therapist or 6. To
counselor as minimize body
needed. changes &
enhance
appearance.

7. Helpful in
identifying
ways/ devices
to regain &
maintain
independence
. Client may
need further
assistance to
resolve
persistent
 emotional
problems.

4. NURSING CARE PROCESS FOR IMPAIRED SKIN INTEGRITY

CUES NURSING SCIENTIFIC GOAL AND INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION OBJECTIVE
The skin serves LONG INDEPENDENT:
Subjective: Impaired skin as the primary TERM: After the
integrity line of defense 1. Assess skin 1. nursing
The client verbalized related to against After the daily. Note Establishes intervention,
“Sumasakit yong surgery bacterial nursing color, turgor, comparative the client able
tahi ko kapag invasion. When intervention, circulation and baseline to improved
gumagalaw ako.” skin is incised the client will sensation. providing wound lesion
for a surgical be able to be Describe opportunity healing.
Objective: procedure, this free measure lesions for timely
important line of of/display and observe intervention.
 Presence of defense is lost improvement changes.
surgical in wound 2.
incision (Source: lesion 2. Maintaining
Maternal and healing. Maintain/instruct clean, dry
Child Health in good skin skin provides
Nursing, SHORT hygiene; e.g., a barrier to
Pillitteri p.567) TERM: wash infection.
thoroughly, pat Patting skin
Surgical After the dry carefully and dry instead of
incisions heal nursing gently massage rubbing
by primary intervention, with lotion or reduces skin
intention or by the client will appropriate of dermal
the gradual be able to cream. trauma to
removal and apply dry/fragile
replacement of The skin.
dead or Intervention Massaging
damaged cells intended to increases
at the wound improve circulation to
site with new condition. the skin and
cells produced promotes
by the comfort.
surrounding
tissue. 3. Reposition 3. Reduces
frequently. stress on
(Source: pressure
Maternal and points,
Child Health improves
Nursing, blood flow to
Pillitteri p. 582) tissues and
promotes
4. Maintain healing.
clean, dry,
wrinkle-free 4. Skin
linen, preferably friction
soft cotton caused by
fabric. movement
over
wet/wrinkled
or rough
sheets leads
to irritation of
fragile skin
 and
5. Encourage increases risk
ambulation / out of infection.
of bed as
tolerated. 5. Decreases
pressure on
skin from
DEPENDENT: prolonged
bedrest.
6. Provide
foam / flotation /
alternate
pressure 6. Reduces
mattress or bed. pressure on
skin, tissue
and lesions.
7. Apply /
administer
topical / 7. Used in
systemic drugs treatment of
as indicated. skin lesions.
 Use of
agents such
as prederm
spray can
stimulate
circulation,
enhancing
8. Refer to healing
physical therapy process.
for regular
exercise / 8. Promotes
activity program. improved
muscle tone
and skin
health.

5. NURSING CARE PLAN FOR FEAR

CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
LONG INDEPENDENT:
Subjective: Fear r/t Fear is an TERM: Client was
surgical emotion or 1. Ask client’s 1. able to
Client verbalized: incision feeling of After nursing feeling about Expressing minimize her
“Takot ako apprehension intervention, her fear. client’s fear
gumalaw kasi baka aroused by the client will feeling may
bumuka ung tahi impending or be able to lessen her
ko” seeming minimize her 2. Encourage fear and ease
danger, pain or fear. contact with a her anxiety
Objective: other perceived peer who has
threat. The fear SHORT successfully 2. Client is
 Patient has may be in TERM: dealt with a more likely to
avoidance to response to an similar situation. believe other
move immediate or After the who have had
 Increased current threat, nursing 3. Discuss to similar
respiratory or in response intervention client proper experience
to something the client will positioning,
the person be able to transferring and
believes will apply ambulation to
happen intervention assure client 3. Provides a
intended to that her suture healthy outlet
(Source: improve will not open. for energy
 Fundamentals condition. generated by
of Nursing 4. Assist client feeling and
p1017) in positioning, promotes
transferring and relaxation
ambulation

6. NURSING CARE PLAN FOR RISK FOR INJURY

CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATIO

DIAGNOSI EXPLANATIO S S N
S N
Risk for Risk for injury LONG INDEPENDENT The client
injury r/t is a state in TERM: was able to
NOTE: Post- which the 1. Assess mood, 1. Some mood, coping demonstrate
operative individual is at After the coping abilities, abilities and personal behavior and
Risk condition risk for injury nursing personal styles. styles might result in lifestyle
diagnosis is as a result of intervention carelessness/increase changes to
not environmental the client will d risk-taking without reduce risk
evidenced conditions be able to consideration after the factors and
by signs interacting with demonstrate consequences. protect self
and the individual’s behaviors, from injury.
symptoms, adaptive and lifestyle 2. To prevent injury in
as the defense changes to 2. Ascertain home, community and
problem resources. reduce risk knowledge of work setting.
has not factors and safety
occurred (Source: protect self needs/injury
and nursing Fundamentals from injury. prevention and
intervention of Nursing 7th motivation. 3. Providing, in a
s are Edition, by SHORT simple and direct
directed at Kozier, page TERM: 3. Provide manner, specific
prevention. 673) information factual information into
After the regarding the the client.
nursing condition that
intervention may result in
the client will increased risk of 4. Discussion
be able to injury. encourages
apply participation by
interventions 4. Discuss the learner.
intended to importance of
improve self-monitoring
condition. condition/emotion
 s that can
contribute to
occurrence of
injury. 5. A discharge note
and referral summary
DEPEDENT are completed when
the client is being
5. Refer to the discharged and
resources as transferred to another
indicated. institution or to a home
setting where a visit by
a community health
nurse is required.

7. NURSING CARE PLAN FOR RISK FOR POSTOPERATIVE POSITIONING INJURY

CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
Risk for Surgery can LONG TERM: INDEPENDENT:
NOTE: Postoperative involve many Client was able
Positioning body systems After nursing 1. Discuss the 1. To increase to be free from
A risk Injury both directly intervention, length of awareness of any untoward
diagnosis is and indirectly the client will procedure and potential of injury
not evident by and is a be able to be customary potential
signs and complex free from any positioning complications
symptoms, as experience for untoward
d problem has the client. injury. 2. Provide 2. To maintain
not occurred Maintain safety measures position and
and nursing respiratory and SHORT ♪ lock/cart bed prevents client
intervention skeletal muscle TERM: ♪ maintain from any injury
are directed at function to body alignment
prevention prevent post After the ♪ protect body
surgical nursing from contact
complications. intervention with metal parts
the client will of the operating
(Source: be able to room
Medical- apply ♪ position
Surgical interventions extremities to
Nursing intended to facilitate
handbook improve periodic
p585) condition. evaluation of
safety,
 circulation,
nerve pressure
and body
alignment
♪ reposition
slowly and at 3. To prevent
transfer and in bed sores and
bed promote skin
and tissue
3. Assist client integrity.
in changing
positions and
transferring

8. NURSING CARE PLAN FOR IMPAIRED BED MOBILITY

CUES NURSING SCIENTIFIC GOAL AND INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION OBJECTIVE
Subjective: LONG INDEPENDENT: The client was
Impaired The sensory TERM: able to
The client bed mobility experience of 1. Assist on / off 1. Facilitates demonstrate
verbalized “Medyo related to pain depends After the bedpan and into elimination. techniques /
nahihirapan akong pain on the nursing sitting position behaviors that
gumalaw kase nga discomfort interaction intervention, when possible. enable safe
dahil sa tahi ko.” between the the client will repositioning.
nervous system be able to 2. 2. Facilitates
“Kailangan dahan- and the demonstrate Demonstrate / self-care and
dahan lang kase environment. techniques / assist with client’s
kapag napamali ng The processing behaviors transfer independence.
galaw kumikirot of noxious that enable techniques and Proper
yong parte na may stimuli and the safe use of mobility transfer
tahi.” resulting repositioning. aids. techniques
perception of prevent
Objective: pain involve the SHORT shearing
peripheral and TERM: abrasions
 impaired central nervous dermal injury
ability: turn system. After the related to
side to side nursing 3. Encourage scooting.
(Source: intervention, continuation of
Medical- the client will exercises. 3. To
Surgical be able to maintain /
Nursing, apply the DEPENDENT: enhance gains
 Brunner and interventions in strength /
Suddarth p. intended to muscle
220) improve 4. Provide control.
condition. foam / flotation
mattress.

4. Reduces
pressure on
skin / tissues
that can impair
circulation,
potentiating
risk of tissue
ischemial
breakdown.

9. NURSING CARE PLAN FOR SELF-CARE DEFICIT

CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
Subjective: LONG INDEPENDENT:
Self-care A self-care TERM: The patient
The patient deficit related deficit exists 1. Provide 1. Privacy has able to
stated, “Eto to Post- when the self- After the privacy during enables a client perform self-
nga hindi ako Operative care agency is nursing personal care to participate care activities
makaligo kasi Incision not able to intervention, activities. without worrying with in level of
masakit…” meet some or the patient about later own ability.
all the will be able to embarrassment.
components of perform self-
Objective: Therapeutic care activities 2. Inspect skin 2. Presence of
Self-Care within level of regularly such lesions may
 Able to Demand. own ability. require treatment
change as well as signal
her SHORT the need for
clothes TERM: closer monitoring
but / protective
unable After the 3. Encourage intervention.
to take nursing scheduling
a bath. intervention, activity early in 3. Clients with
the client will the day or during MS expand a
be able to the time when great deal of
apply the energy level is energy to
interventions test. complete ADL’s,
intended to increase the risk
improve of fatigue, with
condition. often progresses
4. Avoid doing through the day.
things for client
that client can do 4. These clients
for self, may become
providing fearful and
assistance as dependent and
necessary. although
assistance is
helpful in
preventing
frustration it is
important for
client to do as
much as possible
5. Encourage for self to
client to perform maintain self-
 self-care to the esteem and
maximum of promote
ability as defined recovery.
by client. Do not
rush client. 5. Promotes
independence
and sense of
control, may
decrease
feelings of
helplessness.

10. NURSING CARE PLAN FOR DECISIONAL CONFLICT

CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
Subjective: Decisional Uncertainty LONG TERM: INDEPENDENT: The patient
Conflict r/t about course of able to decide
The client lack of action to be After the 1. Encourage 1. Lack of to which
verbalized, relevant taken when nursing verbalization of information institution she
“Noong una, information. choice among intervention, conflict. can interfere gave birth.
hindi dito ang competing the patient will client’s
plano kong actions involves be able to response to
manganak.” risk, loss or decide to 2. Determine illness
challenged to which current situation.
Objective: personal life institution she knowledge.
values. will give birth. 2. Provides
 The clues to assist
client SHORT client to
has (SourceNANDA) TERM: develop
delayed coping and
decision After the 3. Correct regain
-making. nursing misperceptions equilibrium.
intervention, client may have
the client will and provide
be able to information. 3. Provides for
apply the better
interventions 4. Encourage decision-
intended to involvement of making.
improve family as
condition. desired.
DEPENDENT:
4. Assist in
identification
5. Refer to other and correction
resource as of perception
necessary. of reality and
enables
problem
solving to
begin.

5. To provide
support for the
client.
Additional
assistance
may be
needed to
help client
resolve
making
 decisions.

11. NURSING CARE PLAN FOR INEFFECTIVE BREASTFEEDING

CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
Subjective: Ineffective Dissatisfaction LONG TERM: INDEPENDENT: The client
Breastfeeding or difficulty a assumes
The client r/t Knowledge mother, infant After the 1. Assess client 1. Maybe for responsibility
verbalized, Deficit. or child nursing knowledge some reasons for effective
“Ayokong experiences intervention, about that the client breastfeeding.
magpabreastfeed. with the the client will breastfeeding misinterpreted
” breastfeeding be able to and extent of the
process. have effective instruction that instruction.
Objective: breastfeeding. has been given.

SHORT 2. Encourage 2. To assess

TERM: discussion of furthermore.
 current
After the breastfeeding
nursing experience.
intervention,
the client will 3. Maybe she
be able to 3. Determine is in the stage
apply the maternal of “Taking- in
intervention feelings. Phase”.
intended to
improve
condition. 4. Because
4. Give some mothers
emotional wanted to
support to have an
mother. Use 1:1 attention due
instruction with to their
each feeding condition.
during hospital
stay/ client visit.

5. Promote early 5. So that we

 management of can assure
breastfeeding the main
problems. problem of
the client.
6. Encourage
spouse
education and 6. For
support when emotional
appropriate. support to the
mother or the
client.

12. NURSING CARE PLAN FOR RISK FOR INFECTION

NURSING SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EVALUATION

CUES DIAGNOSIS EXPLANATIO
N
NOTE: Risk for LONG TERM: INDEPENDENT:
infection A wound can
Risk diagnosis related to be infected After the 1. Observe for 1. Provides
is not surgical with nursing localized signs of information The patient’s
evidenced by incision microorganism intervention, infection at about the risk for
signs and s at the time of the patient will insertion sites of severity and infection has
symptoms, as injury, during be able to invasive lines, presence of been
the problem surgery, or prevent or sutures, surgical infection. prevented.
has not postoperatively reduce risk of incisions or
occurred and . Surgical infection. wounds.
nursing infection is
interventions most likely to SHORT TERM: 2. Reduces
are directed at become 2. Practice/ risk of
prevention. apparent 2 to After the instruct in Good spread of
11 days nursing Handwashing pathogens
postoperatively intervention the and aseptic
. client will be wound care.
able to apply 3. Provides
Contamination interventions 3. Monitor the information
of a wound intended to vital signs. Note: about the
surface with improve onset of fever, developing
microorganism condition. chills, sepsis and
s (colonization) diaphoresis, abscess.
is an inevitable reports of
result. Because increase
the colonizing abdominal pain. 4. Prevents
organisms introduction
compete with 4. Cleanse of pathogens
new cells for incisions or into the body
oxygen and insertion sites
nutrition, and daily and prn with
because their povidoneiodine or
by-products other appropriate 5. Prevents
can interfere solution. introduction
with a healthy of pathogens
surface 5. Instruct client into the body
condition, the or SO(s) in
presence of techniques to
contamination protect the
can impair integrity of skin, 6. To assess
wound healing care for lesions, the healing
and lead to and prevention of process
infection. spread of
infection. 7. To regain
(Source: energy for
Fundamentals 6. Instruct the faster
of nursing, patient in wound recovery
page 861, healing.
Kozier)
7. Promote quiet 8. To regain
and restful energy for
environment faster
conducive for rest recovery
and sleep.

8. Provide
nutritious food.

DEPENDENT:

9. Administer
medication
regimen
(antibiotic) and
note the client’s
 response to
determine
effectiveness of
therapy or
presence of side
effects.

13. NURSING CARE PLAN FOR FLUID VOLUME EXCESS

CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTIONS RATIONALE EVALUATIO

DIAGNOSI EXPLANATIO S N
S N
Subjective: Fluid Fluid volume LONG INDEPENDENT: After the
volume excess occurs TERM: nursing
The client excess r/t when the body 1. Measure I & O 1. Reflects intervention
verbalized, Pregnancy retains both After the noting positive circulating volume the client was
“Minamanas water and nursing balance (intake in status, able to
ako.” sodium in intervention excess of output). developing/resoluti demonstrate
similar the client will Weigh daily, and on of fluid shifts, fluid volume
Objective: proportions to be able to note gain more and response to balance.
normal ECF. demonstrate than 0.5 kg/day. therapy. Positive
 Edema This is fluid volume fluid balance/weight
commonly balance, with gain often reflects
Measurement: referred to as balanced I & continuing fluid
hypervolemia O, stable retention.
(increased weight, VS 2. Monitor BP. Note
blood volume). within the external jugular and 2. BP elevations
FVE is always client’s abdominal vein are usually
secondary to normal range distention. associated with
an increase in and absence fluid volume excess
the total of edema. but may not occur
sodium because of fluid
content. In SHORT shifts of the
FVE, both TERM: vascular space.
intravascular Distention of
and interstitial After the external jugular
spaces have nursing vein in associated
an increased intervention with vascular
water and the client will 3. Assess the congestion/edema.
sodium be able to respiratory status,
content. apply the noting increased 3. Indicative of
Excess interventions respiratory rate, pulmonary
interstitial fluid intended to dyspnea. congestion/edema.
is known as improve
edema. condition. 4. Auscultate lung,
noting
(Source: diminished/absent 4. Increasing
Fundamentals breath sounds and pulmonary
of Nursing 7th developing congestion may
Edition, by adventitious result in the
Kozier, page sounds. consolidation,
1363) impaired gas
exchange, and
complications, e.g.
pulmonary edema.
5. Monitor for
cardiac 5. May be caused
dysrhythmias. by heart failure,
Auscultate heart decreased
sounds, noting coronary arterial
development of perfusion, or
signs and electrolyte
symptoms (gallop imbalance.
rhythm).

6. Assess degree
of 6. Fluid shift into
peripheral/depende tissues as a result
nt edema. of sodium and
water retention,
decreased albumin,
and increased
antidiuretic
hormone (ADH).
7. Measure
abdominal girth. 7. Reflects
accumulation of
fluids (ascites)
 resulting from loss
of plasma
proteins/fluid into
the peritoneal
8. Provide frequent space.
mouth care;
occasional ice 8. Decreased
chips, schedule sensation of thirst
fluid intake round especially when
the clock. fluid intake is
restricted.
DEPENDENT:

9. Monitor serum
albumin and
electrolytes. 9. Decreased
serum albumin
affects the plasma
colloid osmotic
pressure resulting
in edema
 formation. Reduced
renal blood flow
accompanied by
elevated ADH and
aldosterone levels
and the use of
diuretics may
cause various
10. Monitor serial electrolyte
chest x-rays. shifts/imbalances.

10. Vascular
congestion,
pulmonary edema,
11. Restrict sodium and pleural
and fluids as effusions frequently
indicated. occur.

11. Sodium may be

restricted to
minimize fluid
 retention
extravascular
sources. Fluid
restriction may be
— necessary to
12. Administer salt- correct/prevent
free dilutional
albumin/plasma hyponatremia.
expanders as
indicated. 12. Albumin may
be used to increase
the colloid osmotic
pressure in the
vascular
compartment,
thereby increasing
effective circulating
volume and
13. Administer decreasing
medications as formation of
indicated: ascites.
 13. Used with
caution to control
edema and ascites,
block effect of
aldosterone, and
increase water
secretion while
sparing potassium
when conservative
therapy with bed
DIURECTICS rest and sodium
POTASSIUM restriction does not
POSITIVE alleviate problem.
INOTROPIC
DRUGS and Diuretic given with
ARTERIAL coordination with
VASODILATORS albumin
administration may
enhance fluid
removal. Serum
 and cellular
potassium are
usually depleted
because of liver
disease and urinary
losses. Given to
increase cardiac
output/improve
renal blood flow
and function,
thereby ﾏ±reducing
excess fluid.

14. NURSING CARE PLAN FOR FATIGUE

CUES NURSING SCIENTIFIC OBJECTIVE INTERVENTION RATIONALE EVALUATION

DIAGNOSIS EXPLANATION
LONG INDEPENDENT:
Subjective: Fatigue It is though that TERM:
related to a person who is 1. Discuss 1. Discussion The patient
The client stress moderately After the lifestyle changes encourages has improved
verbalized, “Tulog fatigued usually nursing or limitations participation by sense of
lang ako ng tulog has a restful intervention, imposed by learner and energy.
kasi pakiramdam sleep. Fatigue the patient fatigue. permits
ko lagi akong also affects a will be able reinforcement.
pagod na person’s sleep to improved And repetition at
pagod…” pattern. The sense of learner’s level.
more tired the energy.
person is the 2. Encourage 2. Enhances
Objective: shorter the first SHORT client to do strength/stamina
period of TERM: whatever and enables
 Lethargic paradoxical possible. (e.g. client to become
and Drowsy (REM) sleep. After the self-care, sit-up more active
As the person nursing in chair, walk). without undue
rests, the REM intervention Increase activity fatigue.
periods become the client will level as
longer. be able to tolerated.
apply the
(Source: interventions 3. To lessen
Fundamentals intended to 3. Instruct in fatigue
of Nursing, improve methods to
page 1118, by condition. conserve
Kozier) energy.

4. Weakness
4. Assist with may make
self-care needs; ADL’s different
keep bed in low to complete or
position and place the client
travel ways at risk for injury
clear of during activity.
furniture, assist
with ambulation 5. To lessen the
as indicated. occurrence of
fatigue.
5. Provide
environment
conducive to
relief of fatigue.
Temperature
and level of
humidity are 6. Prevent
known to affect dehydration
exhaustion. which increases
fatigue.
6. Encourage
adequate fluid
intake.