NURSING CARE PLAN

CUES NURSING RATIONALE TO GOALS & NURSING INTERVENTION RATIONALE TO NURSING EVALUATION
DIAGNOSIS NURSING DIAGNOSIS OBJECTIVES INTERVENTION
Subjective: Disturbed The common causes of Short Term Goals: Independent Intervention: Short Term
>SO claims that Thought altered sensorium in an After 8 hours of 1. Monitor at least every 4 hours - Assist in determining Goal:
patient has Process r/t immunocompetent adult in nursing intervention, while awake: pathophysiologic causes -Goal was
different developing our geographical region are the patient will be •Vital signs for Disturbed Thought partially met.
response druing infections sepsis, bacterial meningitis, oriented to place, date • Neurologic status, particularly for Process. Patient recalls
communication secondary to meningoencephalitis, and time. signs and symptoms of ICP time and date,
>SO observed Schistosomiasis hepatic encephalopathy, • Mental status primary reason of
changed of uraemic • Laboratory values for metabolic hospitalization.
sensorium when encephalopathy and other alkalosis, hypokalemia, increased
patient was metabolic Long term goals: ammonia levels, or infection Long Term
asked to take a encephalopathies like After 8-16 hours of 2. Keep initial interactions short but - Facilitates the development Goals:
bath hypoglycaemia and hypon nursing shift, the frequent. Interact with client for of a trusting relationship. - - Goal was
atraemia. Acute onset patient will describe [number] minutes every 30 minutes. incompletely
Objective: altered mental status is a 2-4 strategies to Begin with 5-minute interactions and met. SN was
>Admitting clinically challenging manage distorted gradually increase the times of not able to
diagnosis of situation due to varied thoughts. interactions. communicate
Hepatic presentation with little 3. Be consistent in all interactions - Facilitates the development of well with the
Encelopathy signs to elicit and narrow with the client. a trusting relationship, and patient since
Grade II from therapeutic window. meets the client’s safety needs. she choose to
Liver Cirrhosis 4. Recognize and support the client’s - Focuses on the client’s real rest and sleep
from feelings. Respond to the feelings feelings and concerns. during
Schistosomiasis Sources: being expressed. interactions.
>Continued 5. Have the client clarify those - Facilitates the development Demonstrates
exposure of thoughts you do not understand. Do of a trusting relationship, frustrations
Schistosomiasis http://www.jneuro.com/ne not pretend to understand that which and prevents inadvertent upon
endemic area in urology- you do not. support of the delusional recalling
Pastrana due to neuroscience/sudden- thinking. events or
>Patient onset-altered-sensorium- 6. Provide side rails on bed. - Basic safety measures and answering
exhibits: artery-of-percheron- • Keep the room uncluttered. reinforcement of reality. closed-ended
-Distractability infarct.php?aid=20082 • Reorient the client at each contact. and directing
-Memory deficit • Reduce extraneous stimuli (e.g., questions.
-Hypovigilance limit noise and visitors, and reduce
>V/S: bright lighting).
BP = 110/70mmHg • Use touch judiciously. • Prepare for
HR= 86bpm all procedures by explaining simply
RR= 20cpm and concisely.
T=36.8 degree • Provide good lighting.
7. Design communications according - Enhances communication and
Celcius
to the patient’s best means of quality of care.
>CBC revealed communication (e.g., writing, visuals,
or sound):
-Low • Give simple, concise directions. •
Lymphocytes; Listen carefully.
low • Present reality consistently.
• Do not challenge illogical thinking.
Monocytes; low
8. Facilitate the patient’s use of - Increases sensory input and
albumin- prosthetic or assistive devices (e.g., reinforces reality.
indicative of eyeglasses, dentures, hearing aid, or
inflammation in walker).
the body 9. Provide consistent approach in - Inspires trust, reinforces
nursing care and routine. [Note reality, decreases sensory
routine for this client here.] stimuli, and provides memory
cues.
10. Facilitate self-care to the extent -Increases self-esteem, forces
possible. [Note patient’s abilities reality check, decreases
here.] powerlessness, and provides a
means of evaluating the
patient’s status
Collaborative Intervention:
1. Involve significant others in care, - Provides social support and
and include in teaching sessions. consistency in management.
[Note teaching plan here.]
2. Refer to and collaborate with - Provides for long-term
appropriate assistive resources. support and a more holistic
approach to care
3. Collaborate with psychiatric nurse - Collaboration provides the
clinician and rehabilitation nurse best plan of care.
specialist.
4. Teach the client and family to -Basic monitoring that allows
monitor for signs and symptoms of for early intervention
Disturbed Thought Process:
• Poor hygiene
• Poor decision making or judgment
• Regression in behavior
• Changes in interpersonal
relationship
• Distractibility
4. Involve the client and family in - Involvement improves
planning, implementing, and cooperation and
promoting appropriate thought motivation, thereby
processing: increasing the probability
• Family conference of an improved outcome.
• Mutual goal setting
• Communication
 NURSING CARE PLAN

CUES NURSING RATIONALE TO GOALS & NURSING INTERVENTION RATIONALE TO NURSING EVALUATION
DIAGNOSIS NURSING DIAGNOSIS OBJECTIVES INTERVENTION
Subjective: Ineffective Pattern of regulating and Short term goals: Independent Intervention: Short-term
>Other patients health integrating into daily living After 8 hours of 1. Assist the patient to identify factors - Healthy living habits reduce goals:
and their maintenance a program for treatment of nursing intervention, contributing to health maintenance risk. Assistance is often - Goal was
respective SO r/t lack of illness and the sequelae of the patient or SO will change through one-to-one required to develop long- completely
have been seen ability to make illness that is unsatisfactory - describe at least interviewing and value clarification term change. Identification met. SO
the patient: deliberate and for meeting specific health 1-2 contributing strategies. of the factors significant to verbalized
- manually thoughtful goals factors that lead the patient will provide the poor
removed the judgments to health foundation for teaching compliance
NGT and FBC maintenance positive health maintenance to therapeutic
while health Empowering patients to be alteration 2. Develop with the patient a list of - Increases the patient’s sense regimen due
care providers active participants in their - describe 1 assets and deficits as he or she of control and keeps the to change of
are not present. care plays an important role measure to alter perceives them. From this list, assist idea of multiple changes sensorium
-eats food while in the ongoing changes in each factor the patient in deciding what lifestyle from being overwhelming. and
NPO healthcare. Each patient is adjustments will be necessary. immobility.
>”Ginhuhubya challenged with 3. Identify, with the patient, possible - The more the patient is Demonstrate
hira pagbantay increasingly intricate solutions, modifications, etc., to cope involved with decisions, the willingness
akon”, as therapeutic regimens to be with each adjustment. higher the probability that in
verbalized by managed in the healthcare the patient will incorporate participation
the patient setting and in the home the changes. of nursing
> has hx of non- environment. Moreover, 4. Develop a plan with the patient that - Avoids overwhelming the interventions
compliace to not every patient is able to shows both short-term and long-term patient by indicating that and will
therapeutic reach and access healthcare goals. For each goal, specify the time not all goals have to be accompany
regimen when providers and respectively the goal is to be reached. accomplished at the same patient
diagnosed with expected to assume time. during
DM responsibility for managing 5. Have the patient identify at least - Provides additional support hospitalizatio
the nuances in their disease. two support persons. Arrange for for patient in maintaining n, follow-up
Objective: these persons to come to the unit and plan. check-ups
>Patient Though many individuals participate in designing the health and home
exhibits: want to be active maintenance plan. medications
-Distractability participants and partners in 6. Teach the patient appropriate - Provides the patient with
-Memory deficit their own care, patients information to improve health the basic knowledge needed
-Hypovigilance with sensory perception maintenance (e.g., hygiene, diet, to enact the needed
>V/S: deficits and altered medication administration, relaxation changes.
BP = 110/70mmHg
cognition are not capable of techniques, and coping strategies).
HR= 86bpm doing so. Also, poverty and 7. Review activities of daily living - Incorporation of usual
RR= 20cpm the lack of support systems (ADLs) with the patient and support activities personalizes the
T=36.8 degree are barriers to accessing person. Incorporate these activities plan.
health care when needed. into the design for a health
Celcius
Older patients, who often maintenance plan.
experience these problems,
are especially at high risk
for ineffective management Collaborative Intervention:
of the therapeutic plan or 1. Assist the patient and significant
health maintenance. others in developing a list of potential
strategies that will assist in the
development of the lifestyle changes
necessary for health maintenance.
Source:
- will be more inclined to
https://www.ok.gov/odmhs
as/documents/Treatment%
20Plans%20that%20Impro 2. Communicate the established plan
ve%20Health.pdf to the collaborative members of the
health-care team.
- People most often approach
change with “more of the
same” solutions. If the
individual does not think
that the strategy will have to
be implemented, he or she
develop creative strategies
for change.
- Provides continuity and
consistency in care.
 NURSING CARE PLAN

CUES NURSING RATIONALE TO NURSING GOALS & NURSING INTERVENTION RATIONALE TO NURSING EVALUATION
DIAGNOSIS DIAGNOSIS OBJECTIVES INTERVENTION
Subjective: Constipation r/t Constipation is not a physiologic Short term goal: Independent Intervention: Short term
>SO claims to immobility and consequence of normal aging. After 8 hours of 1. Check on the usual pattern of -The normal frequency of stool goals:
have decline in decreased dietary Many age-related problems nursing elimination, including passage ranges from twice daily -Goal was
intake (e.g., decreased mobility, intervention, the frequency and consistency of to once every third or fourth completely met.
appetite, skips
comorbid medical conditions, patient will stool. day. SO claims to have
meals, eats at increased use of medications establish bowel 2. Identify factors (e.g., - Irregular mealtime, type of BM after 8 hours
least 1-2x/day with a side effect profile that movement. medications, bed rest, and diet) food, and interruption of usual of nursing
>SO have seen includes constipation, and that may cause or contribute to schedule can lead to intervention.
that patient changes in diet) may contribute constipation. constipation.
prefers to lay in to the increased prevalence of 3. Evaluate medication profile - A lot of drugs can slow
bed than show constipation in older adults. for gastrointestinal side effects. down peristalsis. Opioids,
The National Health and antacids, antihypertensive, gene
interest in
Nutrition Examination ral anaesthetics, and iron and
eating Survey found that a low calcium supplements can cause
>So claims that physical activity level is constipation.
patient has no associated with a twofold 4. Assess the patient’s activity -lack of exercise, prolonged bed
BM 3 days PTA increased risk of constipation. level. rest and inactivity contribute to
until present Another epidemiologic constipation.
admission study showed that patients who 5. Instruct SO on the -Inadequate fluid can aggravate
are sedentary are more likely to relationship of diet, exercise, bowel dysfunction.
complain of constipation. and fluid intake to constipation.
Objective: Prolonged bed rest and 6. Encourage verbalization of -Perceptions of the need for
>Has enlarged immobility are often associated feelings about exercise or need exercise may be influenced by
abdoment with constipation. However, the for exercise misconceptions, cultural and
> Hypoactive Nurses’ Health Study, which social beliefs, fears, or age.
bowel sounds; followed a cohort of 62,036 7. Encourage verbalization of -Individuals who have been
<5 borborygmi women, found that physical feelings about exercise or need successful in an exercise
activity two to six times per for exercise. program can assist patient by
heard in four
week was associated with a 35 providing incentive and
quadrants of percent lower risk of enhancing motivation. For
abdomen constipation. example, a walking partner or
> exhibits body assistant may be beneficial.
malaise during A dietary diary may be helpful 8. Determine her motivation to -Activity influences bowel
movement. to assess whether an adequate begin/continue an exercise elimination by improving
>Prefers to lay amount of fiber is consumed program. Inform patient and SO muscle tone and stimulating
daily. Most healthy Americans about the health benefits and peristalsis.
down in bed.
consume 5 to 10 g of fiber physiologic effects of exercise.
>V/S: daily. The daily recommended 9. Assist the patient in -A sitting position with knees
BP = 110/80mmHg fiber intake is 20 to 35 g daily. If assuming a high- flexed straightens the rectum,
HR= 86bpm fiber intake is substantially less fowler’s position with knees enhances the use of abdominal
RR= 20cpm than this, patients should be flexed
T=36.7 degree encouraged to increase their
Celcius intake of fiber-rich foods such as
bran, fruits, vegetables, and
nuts. Prune juice is commonly
used to relieve constipation.
- pharmacological treatment of
https://www.aafp.org/afp/2005/
1201/p2277.html
- Brunner and Suddarth’s
medical surgical nursing 12th
edition. Vol.1
10. Assist patient and SO to
set short-term and long-term
goals for the exercise program
11. Check doctor’s order for
treatment
12. Explain the use of
pharmacological agent as
ordered.
Dependent Intervention:
1. Administer enema or laxative
or suppositories as ordered.
Collaborative Intervention:
1. Instruct the SO about
appropriate types of exercise
for her level of health, in
collaboration with a primary
care provider.
muscles, and facilitates
defecation.
- Realistic goal setting provides
direction and motivation.
-Identify specific medication to
administer
- The use of laxatives or
enemas is indicated for short-
term management of
constipation.
-These laxatives aid in
softening stools and stimulate
rectal mucosa; best results
occur when given 30 minutes
before usual defecation time or
after breakfast.
-Any individual beginning an
exercise program should
consult a primary care provider
primarily for a cardiac
evaluation.