NURSING CARE PLAN

NURSING
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

1.) Monitor vital signs.  For Baseline data.

Subjective: Activity Intolerance r/t Short term:
fatigue and malaise 2.) Assess level in  Provide baseline for
“Akong gina buhat Within 4 hours of activity intolerance and further assessment
lang dari kay mag duty, the student nurse degree of fatigue, and criteria for
higda ra og mag will be able to teach lethargy, and malaise assessment of
lingcod pero dili kaayo and demonstrate to when performing effectiveness and
ko mag lihok-lihok.” As the patient the ADL’s . interventions.
verbalized by the importance of
patient. activities/exercise. 3.) Assist with  Promotes exercise &
activities and hygiene hygiene with in pts
when fatigue. level of tolerance.
Long term:
4.) Encourage rest  Conserve energy &
Objective: After 3 days of duty, when fatigue or when protects liver.
the patient will be able abdominal
T: 37.0 C to participate/do an pain/discomfort  Stimulates pts
HR: 90 bpm ADL’s on her own or occurs. interest in selected
RR: 18 cpm with her SO and to activities.
BP: 90/70 report the decrease in 5.) Assist with
fatigue. selection and pacing of  Provides calories for
Body desired activities and energy & protein for
malaise/Generalized exercise. healing.
weakness, sedentary
lifestyle 6.) Provide diet high in  Provides additional
carbohydrates with nutrients.
protein intake
 consistent with liver
function.

7.) Administer
supplemental vitamins
(A, B complex, C, and
K)
 NURSING CARE PLAN

NURSING
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

1.) Assess degree of  Assists in

Subjective: Impaired skin integrity Short term: discomfort r/t edema determining
“Naghubag akung ti.il r/t edema appropriate
dayun bugnaw sya Within 4 hours of interventions.
hikapon” as verbalized duty, the student nurse
by the patient will be able to 2.) Note and record  Provide baseline for
the extent of edema. detecting changes
and evaluating
effectiveness of
Objective: Long term: interventions.

T: 37.0 C After 3 days of duty, 3.) Keep pts fingernails  Prevents skin
HR: 90 bpm the patient will be able short and smooth. excoriation and
RR: 18 cpm to decrease potential infection from
BP: 90/70 pressure ulcer scratching.
development; breaks
in skin integrity. 4.) Provide frequent  Removes waste
skin care; avoid use of product on skin while
soaps and alcohol- preventing dryness
based lotion. of skin.

5.) Assess skin  Edematous skin and

integrity every 4-8 hrs tissue has
and instruct pt and SO compromised
in this activity. nutrient supply and
is vulnerable to
pressure and
trauma.
6.) Restrict sodium as
prescribed.  Minimize edema
formation.

7.) Perform range of  Promotes

motion exercises every mobilization of
4 hrs; elevate edema.
edematous extremities
whenever possible.
 NURSING CARE PLAN

NURSING
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

1.) Restrict sodium  Minimizes formation

Subjective: Fluid volume excess r/t Short term: and fluid intake if of ascites and
to ascites and edema prescribed. edema.
formation Within 4 hours of
duty, the student nurse 2.) Administer diuretics  Promotes excretion
will be able to potassium and protein of fluid through the
Objective: supplement as kidney and
prescribed. maintenance of
T: 37.0 C normal fluids and
HR: 90 bpm electrolyte
RR: 18 cpm imbalance.
BP: 90/70
Long term: 3.) Record intake and  Indicates
output every 1-8hrs effectiveness of
After 3 days of duty, depending on treatment and
the patient will be able response to adequacy of fluid
to restore the normal interventions and on pt intake.
fluid volume. acuity.

4.) Measure and  Monitors changes in

record abdominal girt ascites formation
and weight daily. and fluid
accumulation.
5.) Explain rationale  Promotes pt’s
for sodium and fluid understanding of
restriction. restriction and
cooperation with it.
6.) Prepare pt and
assist with  Paracentesis will
paracentesis. temporarily decrease
amount of ascites
present.
 NURSING CARE PLAN

NURSING
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

1.) Assess dietary  Identifies deficits in

Subjective: Imbalanced nutrition: Short term: intake and nutritional nutritional intake and
“Gagmay ra akung less than body status through diet adequacy of
ginakaon usahay requirements, related Within 4 hours of history and diary, daily nutritional state.
akung i-sud.an sa to abdominal duty, the student nurse weight measurements
pamahaw kay kape, distention and will be able and laboratory data.  Provides calories for
energen, dli na kaau discomfort and energy, sparing
ko mukaon kong anorexia. Long term: 2.) Provide diet high in protein foe healing.
unsa’y ghatag sa carbohydrates with
ration” as verbalized After 3 days of duty, protein intake
by the patient. the patient will be able consistent with liver
function.

Objective: 3.) Assist patient in  Reduces edema and

identifying low-sodium ascites formation.
T: 37.0 C foods.
HR: 90 bpm
RR: 18 cpm 4.) Elevate the head of  Reduces discomfort
BP: 90/70 the bed during meals. from abdominal
distention and
Body decreases sense of
malaise/Generalized fullness produced by
weakness, sedentary pressure of
lifestyle abdominal contents
 and ascites on the
stomach.
5.) Offer smaller, more
frequent meals  Decreases feeling of
fullness, bloating
6.) Encourage patient
to eat meals and  Encouragement is
supplementary essential for the
feedings. patient with anorexia
and gastrointestinal
discomfort.

7.) Encourage
increased fluid intake  Promotes normal
and exercise if the bowel pattern and
patient reports reduces abdominal
constipation. discomfort and
distention.
 NURSING CARE PLAN

NURSING
CUES OBJECTIVE INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

1.) Assess signs and  Fever may indicate

Subjective: Risk for infection Short term: symptoms of infection infection.
especially
“.” As verbalized by the Within 4 hours of temperature.
patient. duty, the student nurse
will be able to identify 2.) Emphasize the  It serves as a first
ways to reduce risk for importance of hand line of defense
infection. washing technique. against infection.

Objective: 3.) Maintain aseptic  Regular wound

Long term: technique when dressing promotes
T: 37.0 C changing fast healing and
HR: 90 bpm After 3 days of duty, dressings/caring drying of wounds.
RR: 18 cpm the patient will not wound.
BP: 90/70 manifest any signs and
symptoms of 4.) Keep area around  Wet area can be
Body infections. wound clean and dry. lodge area of
malaise/Generalized bacteria.
weakness, sedentary 5.) Emphasized
lifestyle necessity of taking  Premature
antibiotics as ordered. discontinuation of
treatment when
client begins to feel
well may result in
return in return of
infection.