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NURSING CARE PLAN

CUES NURSING RATIONALE GOALS/ NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTIONS

Subjective: Acute pain This is due to Short Term Goal:1. After 8 hours of
related to clinical Entry of Independent rendering effective
“Masakit ang tiyan manifestations of pathogens in Within 8 hours of • Use non-pharmacologic • The use of noninvasive pain nursing
ko” as verbalized by circulation effective nursing technique: relief measures can increase
the patient. dengue intervention the
leading to intervention patient  Deep breathing the release of endorphins
hemorrhagic release of anti- will be able to feel and enhance the therapeutic goal was partially
fever technique met as evidenced
inflammatory less pain on his effects of pain relief
 Imagery
mediators and abdomen. medications. by less guarding of
 Distraction
as a vascular stomach and
Objective: techniques
response it patient’s verbalize
 Relaxation
cause increase Long Term Goal: partial relieve of
Guarding of stomach exercises
in capillary
- Facial grimace  Hot or Cold pain.
permeability After period of
- Pain scale of compress
leading to hospitalization,
Characteristic: hyperemia and the patient will
cellular
be able to • Gravity localizes
exudation, • Keep at rest in semi- inflammatory exudates into
Onset: maintain a relax Fowler’s position.
swelling and lower abdomen or pelvis,
pain and calm relieving abdominal
Location:
abdomen. tension, which is
Duration: heightened by supine
position.
Exacerbations:

Radiation: • One of the primary

Dependent:
 mechanisms of
Relief: >Administered Ranitidine hydrochloric acid secretion
30 mg intravenously is histamine stimulation of
Every 8 hours histamine (H2) receptors
on the stomach’s parietal
cells. The H2 antagonists
act by blocking H2
receptors, resulting in a
decrease in the volume of
acid secreted. The pH of
the stomach contents rises
as a result of the reduction
in acid.

CUES NURSING RATIONALE GOALS/ NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTIONS

Subjective: Ineffective Decrease in After 8 hours of 1. 1. a.)To help elevate After 8 hours of
Tissue Perfusion oxygen resulting nursing 2. 1. a.) Encourage patient to hemoglobin and nursing
“Nahihilo, Related to in the failure to intervention, the take iron supplements hematocrit levels intervention the
nanghihina at Decreased nourish the client will be able and eat foods rich in client was:
sumasakit ang hemoglobin tissues at the to: iron.
tiyan ko” as concentration in capillary level b.) Elevate head of bed to 1.
verbalized by the 2. Demonstrate b.) To promote circulation Demonstrated
blood as [Tissue perfusion about 10 degrees. and venous drainage.
patient. evidenced by problems can different ways different ways
low hemoglobin exist without to improve c.)To avoid increased to improve
and hematocrit decreased blood c.) Discourage strenuous oxygen demand. blood
Objective: level. cardiac output; oxygenation activities. oxygenation
and circulation. 2. a.) To help client and
however there 2. a.) Provide health teaching
• Hemoglobin understand his health
may be a
 = relationship 3. Verbalize regarding DHF condition. circulation.
between cardiac understanding
• Hematocrit = b.) Provide health teaching b.)To maintain 2. Verbalized
output and tissue of condition and on drugs being taken. compliance to meds. understanding
perfusion.] importance of
treatment 3. of condition
3. a.)Serve as basis for and
regimen. 3. a.) Monitor vital signs
any alteration in system importance of
Source: .
3. Demonstrate functions. treatment
Nurse’s Pocket increased tissue b.) Encourage early regimen.
b.) Enhances venous
Guide Ninth perfusion. ambulation when return. 3. Demonstrated
Edition possible.
increased
Collaborative: tissue
• Administer medications as • Help control/alleviate perfusion
ordered symptoms

• Administer and regulate • Maintain hydration and

IVF as ordered help wash away toxins

Aids in establishing blood

replacement needs &
Monitor lab studies ( Hb,Hct, monitoring effectiveness
RBC count) of therapy.

Source:

Source: Nurse’s Pocket Guide Ninth

Edition
Nurse’s Pocket Guide Ninth
Edition
 CUES NURSING RATIONALE PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective: Independent: Short term:
Short Term:
Risk for Irregular Goal Met.
After 3 hrs of
“tatlong araw na constipation related defecation habits Provide comfortable To ease patient’s anxiety and
nursing
akong hindi to irregular of one or two environment to help the patient recover Patient have
interventions
dumudumi”, as defecation habits as times per week faster for proper hygiene of demonstrated
patient will
verbalized by the evidence by may cause the the patient behavior changes
demonstrate
patient defecate once or stool to harden to developing
behaviors
twice per week and dry. It may Provide comfort measures by For proper hygiene of the problem
changes to
Objective: also cause AM care, changing the linen patient
developing
infection which and touch therapy Long term:
problem
 irregular may lead to
defecation constipation Provide safety by placing To avoid patient from injury Patient shall have
Long Term:
habits pillows at the side of the be improve her
 inadequate bowel pattern
After 2 days of
toileting Auscultate abdomen for To improve consistence of the
nursing
 recent presence, location and stool and facilitate passage
interventions
environmen characteristics of bowel through colon. For impact
patient will
tal changes sounds.Encourage balance effect of change in bowel
improve her
 change in fiber and bulk habit. Promote function and bowel sounds
bowel pattern
usual adequate fluid intake, aids in reflecting bowel
eating including water and high- activity
pattern fiber fruit juice; also suggest
 >ignoring drinking warm fluid
urge to
defecate Ascertain frequency, color, Provide as baseline of
consistence, amount of stools comparison, promotes
recognition of changes

Educate client/SO about safe Information can help client to

 and risky practice for make beneficial choices when
managing constipation needed

Review medical/ surgical To identify condition

history commonly associated with
constipation

Review appropriate use of To determine if drugs

medication. Discuss client’s contributing to constipation
current medication regimen can be discontinue or change
with physician

Cues Nursing Rationale Planning Intervention Rationale Evaluation

Diagnosis
Subjective: Risk for Risk of Injury as a result Short Term: -Assess the signs and -The GI tract is the most -After 3 hours
N/A hemorrhage of environmental -After 3 hours symptoms of GI bleeding. usual source of bleeding of of nursing
related to altered conditions interacting of nursing Check for secretions. its mucosal fragility interventions,
clotting factor with the individuals interventions, Observe color and the client is
adaptive and defensive the client will consistency of stools or able to
resources. It is also be able to vomitus. demonstrate
Obejective: because of the infection demonstrate -Observe for presence of -Sub-acute disseminated behaviors that
-restlessness of DHF I Virus that behaviors that petichiae, ecchymosis, intravascular coagulation reduce the risk
-petechiae on destroys the platelets reduce the risk bleeding from one more may develop secondary to of bleeding.
lower which place the patient of bleeding. sites altered clotting factor.
extremities at risk of bleeding. Long Term:
- decreased When the blood vessels Long Term: -Monitor pulse, BP -an increase in pulse with
platelet count are cut or damage , the After 1 day of decrease BP can indicate loss After 1 day of
loss of blood from the nursing of circulating blood volume. nursing
system must be stop interventions, intervention,
before shock and the patient’ will -Note changes in level of -Changes may indicate the patient’ will
possible death may be free from consciousness. cerebral perfusion problems. have been
occur. This is injury free from
accompanied by -Encourage use of soft -Minimal trauma can cause injury.
solidification of the toothbrush. Avoid straining mucosal bleeding
blood, a process called in stool, and forceful nose
coagulation or clotting. blowing.
If the value should stop
below normal,(150,000 -Use small needles for -Minimize damage to tissues,
-450,000 g/dl), there is a injections. Apply pressure reduce risk for bleeding and
danger of uncontrolled to venipuncture sites for hematoma.
bleeding because of the longer than usual.
essential role that
platelets have in blood -Recommend avoidance of > Prolongs coagulation,
clotting. aspirin containing products potentiating risk of
hemorrhage