NURSING CARE PLAN NO.

1
Cues Nursing Diagnosis Desired Outcome Interventions Rationale Evaluation
Subjective Cues: Ineffective breathing After 1 week of Independent Interventions: After 1 week of effective
pattern r/t critical illness effective nursing 1. Assess the work of breathing, 1. For early detection of nursing intervention, the
Objective Cues: of rheumatic heart intervention, the patient use of accessory muscles, and respiratory distress, patient was able to establish a
- Adventitious crackles upon disease will be able to establish the presence of retractions and prevention of normal, effective respiratory
auscultation a normal, effective further complications. pattern as evidenced by
- Tachypnea respiratory pattern absence of tachypnea and
- Use of accessory muscle 2. Assist the patient in 2. Optimizes lung normal respiratory rate of 20
when breathing positioning to improve expansion and bpm
- Irregular breathing pattern breathing efficiency (elevate oxygenation, and
- Respiratory rate: 30 bpm the head of the bed, semi- improve respiratory
Fowler's position). muscle function.

3. Monitor and record the 3. Provides baseline data

patient's vital signs and optimize patient
outcomes
4. Regulate IVF according to 4. To ensure correct
rate amount of fluid drips
into your veins.
5. Monitor intake and output 5. Indicates fluid balance
accordingly and ensure proper
intake
6. Encourage rest and limit 6. Help decrease
activities to decrease oxygen respiratory distress and
demand. promote optimal
 oxygenation.

7. Encourage the patient to use 7. Deep breathing

deep breathing techniques to techniques can help
improve lung expansion and reduce anxiety and
oxygenation. promote relaxation,
which can improve the
patient's overall well-
being and help reduce
the risk of respiratory
complications
associated with stress
and anxiety.

NURSING CARE PLAN NO. 2

 Cues Nursing Diagnosis Desired Outcome Interventions Rationale Evaluation
Subjective Cues: Risk for infection r/t Within 2 hours of nursing Independent Interventions: After 2 hours of nursing
“Di na nako ma agwanta inadequate hygiene as intervention, the patient 1. Review client’s 1. Laboratory tests intervention, the patient
ang kakatol, maong ako evidenced by the will be able to verbalize laboratory data provide baseline data was able to verbalize
nalang gikalot.” patient's poor hygiene understanding of about the client's understanding of
Objective Cues: practices and exposure individual risk factors. current health status, individual risk factors as
- Rashes on skin to infectious agents. which can be used to evidenced by “kasabot
- Wound on IV site monitor changes over nako nga kailangan gd
- Long fingernails with time. nako putlan akong kuko
minimal dirt 2. Monitor and record vital 2. Establishes baseline aron pag mangatol ko
- Itching on skin signs data and helps monitor dili dayun masamad ug
- Laboratory results: patient’s condition ma infection.”
 Increased levels of 3. Regulate IVF according 3. To ensure correct
WBC – 13.46 to rate amount of fluid drips
 Low levels of into your veins
lymphocytes – 17 4. Monitor intake and 4. Indicates fluid balance
output accordingly and ensure proper
intake
5. Encourage patient to 5. Fingernails can harbor
frequently trim bacteria and other
fingernails and free from pathogens, which can
dirt be easily transferred to
other people or
surfaces. Frequent
trimming and cleaning
of fingernails can help
prevent the spread of
infection.
6. Teach the patient about 6. Prevent the spread of
 NURSING CARE PLAN NO. 3

Cues Nursing Diagnosis Desired Outcome Interventions Rationale Evaluation

Subjective cues: Acute pain r/t biological Within 5 hours of Independent: After 5 hours of nursing
“Sakit akong tuhod ug injury as evidenced by joint nursing intervention, the 1. Take and monitor vital 1. Establishes baseline intervention, the patient
bagtak pag bugnaw ang pain patient will be able to signs data was able to report pain is
palibot unya mo ngongol report pain is relived relived as evidenced by
mao na akong ipa hilot 2. Assess the type of pain 2. To determine the patient verbalizing “niarang
hilot” the client is characteristics of arang na akong paminaw
Objective cues: experiencing pain unya dili na pod ngolngol”
-Pain assessment: 3. Identify contributing 3. To determine if
P – cold environment factors to pain these conditions can
triggers the pain cause, precipitate,
Q - throbbing pain and exacerbate
R – travels in the joints persistent pain
S - 5/10 4. Assist in/or review 4. To help identify
T - intermittent diagnostic testing factors contributing
to pain
5. Evaluate client’s 5. Passive and
pattern of coping and avoidant behavioral
locus of control patterns or lack of
active engagement
can contribute to
perpetuation of
chronic pain.
6. Evaluate pain behavior 6. Pain behaviors can
using pain rating scale include same ones
present in acute pain
and complaints is
based on client’s
perception
7. Encourage 7. To address issues of
participation in unresolved pain
multidisciplinary pain issues and to set
management plan goals for pain relief.
8. Recommend non 8. To obtain comfort,
pharmacological improve healing and
interventions and decrease
methods of pain dependency on
control analgesics.
9. Assist family in 9. Positive
developing coping reinforcement; this
strategies can aid in focusing
energies on more
productive activities
10. Encourage client to 10. Replacing negative
use positive thoughts with
affirmations positive ones can be
helpful with pain
management
11. Be alert to changes in 11. To determine if
 pain characteristics there are indications
of a new physical
problem or
developing
complication
12. Provide anticipatory 12. Promotes
guidance to client in independence and
which pain is common control on pain
and educate about
when, where and how
to seek intervention
and treatments.
13. Encourage and assist 13. This may benefit
family members/SO to the client through
learn home care reduction of pain
interventions level

Dependent:
1. Administer
Paracetamol 500mg
prn as ordered
 NURSING CARE PLAN NO. 4
Cues Nursing Diagnosis Desired Outcome Interventions Rationale Evaluation
Subjective Cues: Hyperthermia r/t Within 6 hours of nursing Independent Intervention: After 6 hours of nursing
“Gitugnaw ko gaina mawna nag bukot dehydration intervention, the client’s temp 1. Monitor and record 1. Establishes baseline data intervention, the client’s
ko ug habol” will lower down from 38.1 °C vital signs temp will lower down
to within the normal range of 2. Monitor client’s intake 2. Evaluates client’s fluid from 38.1 °C to 37.2°C
Objective Cues: 36.5-37.5°C and output volume as evidenced by client
- Flushed skin 3. Remove excess 3. Promotes heat loss and verbalizing “dili na man
- Warm to touch clothing or layers from increase evaporative tugnaw, arang arang na
- Dry mouth and throat the client cooling akong paminaw karon.”
upon inspection 4. Encourage client to 4. Replenishes fluids lost and
- Fatigue drink fluids such as lowers the body
- Headache water, fruit juice, etc. temperature
- Temperature: 38.1°C 5. Provide a cool, damp, 5. Timid sponge baths reduce
- Sodium (129.0 – washcloth or cool packs fever and make client feel
Decreased level) to patient’s forehead, comfortable
neck, and axilla
6. Encourage client to rest 6. To reduce the production of
and avoid physical excess body heat
activity
7. Educate client and 7. Health teaching is the best
family about way to inform client of the
importance of risks and how to prevent
maintaining adequate from occurring
fluid intake and how to
recognize signs of
 dehydration
8. Provide a cool 8. Helps lower the client’s
environment such as a temperature
room with electric fans
and aircon.

Dependent Intervention:
1. Administer Paracetamol
500mg prn as ordered

NURSING CARE PLAN NO. 5

Cues Nursing Desired Outcome Interventions Rationale Evaluation
Diagnosis
Subjective cues: Ineffective fluid Within 6 hours of - Note possible conditions or - Helps prevent dehydration and other After 6 hours of
“Yellow lagi ako ihi volume r/t nursing processes that may lead to related health problems. Being aware nursing
ma’am, ug sa isa ka insufficient fluid intervention, the deficits in fluid loss of this promotes good health and intervention, the
adlaw pod ky kaisa intake patient will be able prevent dehydration related patient was able
or kaduha rako to maintain fluid complications to maintain fluid
mangihi hantod volume at a - Review client’s laboratory - This evaluates fluid and electrolyte volume at a
karon na admit nako functional level data status functional level as
mao ra gihapon - Monitor and record vital - Establishes baseline data and helps evidenced by
akong ihi.” signs monitor patient’s condition increase in fluid
- Regulate IVF according to - To ensure correct amount of fluid drips intake, normal
rate urine output, and
Objective cues: - Monitor intake and output into your veins normal vital
- decrease in urine accordingly - Indicates fluid balance and ensure signs.
output (1 or 2 times - Encourage client to proper intake
a day only) increase fluid intake orally - To replenish fluids in the body and help
- less water intake such as drinking water, replace electrolytes that have been lost
(700 ml) fruit juice, etc. in the body
- lethargic
- dry lips upon - Educate the client about - Health teaching is the best way for
observation importance of maintaining client to be aware of risks and how to
- pallor an adequate fluid intake. prevent dehydration complications.