NURSING CARE PLANS

Diagnosis /
Assessment Planning Interventions Rationales Evaluation
Cause Analysis
Subjective:
Risk for hemorrhage SHORT TERM GOAL: o V/S taken and o for future SHORT TERM GOAL:
“Tinutubuan nga ko ng
related to decreasing recorded comparison and to
pula pula dito sa binti tapos
clotting factor secondary to Within 30 mins of nursing note any signs of Within 30 mins of nursing
sa paa”, as verbalized by interventions, the client will hemorrhage interventions, the client
viral lysis of platelets.
the client. verbalize understanding on verbalized understanding on
factors that contribute to o Assessed the point o to provides factors that contribute to
Objectives: possibility of injury through of comprehension opportunity to assure possibility of injury as
o WBC = 3.6 x 109/L Aedes Aegypti demonstration of safety regarding factors that accuracy and evidenced by “siyabut akun
↓ practices such as raising contribute to possibility completeness of ago ipunggulalan akun”.
o Platelet = 151 x 109/L
side rails, putting pillows of injury. knowledge base for
o Petechial rash Dengue Virus and changing position every future understanding.
(maculopapular) on ↓ 2 hours as evidenced by o Assessed level of
extremities verbalization in any ways consciousness and o assist in determining
IgG adheres to
o Lymphoctytes 80% same as the context of cognitive level pt. ‘s ability to protect
the platelet
o Neutrophil 20% (initiates destruction “Naiintindihan ko”. self and comply with
o Weakness of the platelet) required self protective
↓ actions LONG TERM GOAL:
o Restlessness
LONG TERM GOAL: o Observed for stool
thrombocytopenia o permits detection of Within 7 hours of nursing
color, consistency and
(50,000/mm3 or
Within 7 hours of nursing amount bleeding in GI tract interventions, the client and
less)
↓ interventions, the client and SO demonstrated behaviors
SO will demonstrate o Observed for that help be free from injury
Increased potential for o it indicate altered
behaviors to reduce risk or hemorrhagic and protect client from self-
hemorrhage clotting mechanism
will be free from injury and manifestation, injury as evidenced by:
(epistaxis)
ecchymosis, epistaxis, a. Ate fruits apple and
↓ protect client from self-injury
Petechiae, and
through boosting immune banana as her snack
stimulates bleeding gums
system by eating foods rich and vegetable stew
intense
inflammatory in vitamin C and having o Provided safe b. Pillows supporting
response adequate fluid intake, environment (pad, side o minimizes injury to legs
↓ pillows on extremities and rails, prevent falls) occur c. Has no sign of
continuous changing of hemorrhage, seen.
petechial rash,
high fever, position as evidence by free o Instructed to change
headache from injury. positions at least every o reduces risk of
2 hours. tissue ischemia/injury
and promote good
body circulation
 Assessment
Subjective:
“Wala akong gana ngayon
eh, kahit sa pag-inom wala
rin… ganto talga ko pag
may lagnat”, as verbalized.
Objectives:
o Oral Fluid intake of 150
cc for the last 8 hours
o Weakness
o slightly dry lips
Assessment
Diagnosis Planning Interventions Rationales Evaluation
SHORT TERM GOAL: o Assessed etiological o to know the cause SHORT TERM GOAL:
Risk for Fluid volume
Within 1 hour of nursing factors which should also be Within 1 hours of nursing
deficit related to increased treated
interventions, the patient interventions, the patient
metabolic rate secondary
will be able to verbalize the verbalized the importance
to inflammatory response o indicator of
importance of maintaining o Assessed skin of maintaining fluid balance
dehydration
fluid balance through giving turgor and moisture as evidence by “Yung
the significance of Tepid pagdagdag ng tubig...
Infected cells by dengue
sponge bath, increasing o Monitored o decrease body siyabut akun ago
virus generate cellular
fluid intake and balance temperature fluids through ipunggulalan akun”.
response
body fluid as evidence by perspiration and
↓
verbalization in any ways increase respiration.
Immune response same as the context of
o to ensure accurate
“Naiintindihan ko”. o Monitored I & O
↓ picture of fluid status
balance being aware of
Pyrogen release insensible loses
↓ LONG TERM GOAL: o TSB promotes heat
LONG TERM GOAL:
Within 7 hours of nursing o Gave tepid sponge loss through conduction
Within 7 hours of nursing
sensed by interventions, the patient bath and evaporation
interventions, the patient
Hypothalamus will be able to maintain
maintained adequate fluid
↓ adequate fluid volume at a o to maintain
hydration status volume at a functional level
functional level through
giving supplemental Fluid o Advised patient to as evidenced by:
resetting the
body’s thermostat as ordered and increase increase oral intake a. taken additional 5
o Replaces lost fluid
to febrile level oral fluid intake as glasses of water
↓ evidenced by atleast COLLABORATIVE: b. SO continuous TSB.
additional 4 glasses of o Provided
Febrile states decrease water and continuous TSB. supplemental fluids (IVF
body fluids through D5LR 1L @ KVO) as o The drug may
perspiration and increase indicated. relieve fever through
central action in the
respiration.
hypothalamic heat-
o Paracetamol 500mg regulating center.
q4 RTC
Diagnosis Planning Interventions Rationales Evaluation
DRUG STUDY
Nursing
Drug / Dosage Drug Action Contraindications Adverse Effects
Considerations

GENERIC NAME:
Ceftriaxone
INDICATION & DOSAGE
 To increase intracranial
pressure and brain mass
ADULT:
150 cc IV bolus then 100 cc
IV every 8 hours
Osmotic Diuretic:
Increases osmotic pressure of
plasma in glomerular filtrate,
inhibiting tubular reabsorption
of water and electrolytes
(including Na and K).
 Active cranial bleeding
 Anuria secondary to
severe renal failure
 Progressive heart failure
 Severe dehydration
CNS: dizziness, headache,
seizure
CV: Chest pain, hypotension,
heart failure, vascular failure
GI: nausea, vomiting,
diarrhea, dry mouth
GU: Polyuria
Metabolic: dehydration,
metabolic acidosis
Other: chills, fever, thirst,
edema
Use cautiously in the
given contraindicated
individual.
Withhold drug until
adequate renal function
and urinary output are
established
Monitor IV site carefully
to avoid extravasation
and tissue necrosis.
Watch for excessive
fluid loss and sign and
symptoms of
hypovolemia and
dehydration

Assess for any signs of

circulatory overload
 Nursing
Drug / Dosage Drug Action Contraindications Adverse Effects
Considerations

 Hypersensitivity to drug  Monitor blood pressure

GENERIC NAME: CNS: dizziness, headache,
Antihypertensive or its components. to evaluate drug efficacy.
Losartan fatigue, insomnia
Potassium Blocks vasoconstricting and
 Assess liver and kidney
CV: hypotension
aldosterone-secreting effects function tests and
of angiotensin II at various ENNT: sinus disorders electrolytes levels.
INDICATION & DOSAGE
receptor sites, including  Instruct patient to avoid
GI: nausea, vomiting, diarrhea,
 Hypertension vascular smooth muscle and dyspepsia, abdominal pain potassium supplements
 To prevent and salt substitutes
cerebrovascular accident adrenal glands.
Metabolic: hyperkalemia containing potassium,
(stroke) in hypertensive
patients with left unless directed by
Respiratory: dry cough
ventricular hypertrophy prescriber.
(LVH)

ADULTS:
50mg 1 tab once a day
 Nursing
Drug / Dosage Drug Action Contraindications Adverse Effects
Considerations

ANTI-ULCER: CNS: headache, agitation,  Assess patient for

GENERIC NAME:  Contraindicated in anxiety. abdominal pain. Note
Ranitdine HCl patients hypersensitive to
Completely inhibits action of presence of blood in
drug and those with GI: nausea, vomiting, diarrhea, emesis, stool, or gastric
histamine on the H2 at porphyria constipation, abdominal aspirate
INDICATIONS & discomfort or pain.
receptor sites of parietal cells,
DOSAGE  Use cautiously in  Remind patient to take
decreasing gastric acid patients with hepatic Skin: rashes. once daily prescription
 Active Duodenal ulcer secretions dysfunction. Adjust dose in drug at bedtime for best
Other: pain at I.M. injection results
 Maintenance therapy for patients with impaired site, burning or itching at I.V.
gastric and duodenal ulcer renal function site, hypersensitivity reaction.  Instruct patient to take
without regard to meals
ADULTS: because absorption isn’t
75mg/Tab NOW affected by food