Nursing Care Plans

NURSING CARE
PLANS
71
IDEAL
NURSING CARE
PLANS
1. Fluid Volume Deficit related to hypotonic dehydration.

2. Diarrhea related to gastrointestinal irritation.
3. Imbalanced Nutrition: less than body requirements related to difficulty absorbing nutrients.
4. Ineffective Airway Clearance related to excessive mucus.
5. Impaired Skin Integrity related to surgery.
6. Delayed Development related to inadequate nutrition.
7. Risk for Infection related to surgery.
72
1st Priority
Name: Jaun Turtola
Admitting Physician: Dr. Sansa Stark
Nursing Diagnosis: Impaired Physical mobility related to abdominal incision secondary to post cholecystectomy
Reference: Doenges, M.E., Moorhouse, M. F. and Murr, A. C. (2012). Nursing Care Plans, Guidelines for Individualizing Client Care Across
the Life Span. 14th ed. P. 328. F. A. Davis Company; Pennsylvania.
Figure 28.
Assessment Objectives Interventions Rationale
Subjective: Short term: Independent:
Thirst, as verbalized by the At the end of the 12-hour shift, Assess vital signs, noting rapid changes of vital
mother for frequency of the clients mother will be able to heartbeat and thread peripheral signs are
breastfeed demand verbalize understanding of causative pulses. associated with
factors and purpose of individual fluid volume loss
Objectives: therapeutic interventions and Observe urinary output and determines fluid
medications and demonstrate note the color. volume status
- Weight loss behaviors to monitor and correct Review laboratory data. to evaluate bodys
- Decreased skin turgor deficit, as indicated. response to fluid
loss
- Increase body
Long term: Encourage mother for provision for
temperature
breastfeeding per demand. increase fluid
- Increased pulse rate; At the end of the 2-day duty, intake
decreased pulse volume the client will be able to maintain
and pressure fluid volume at a functional level as Maintain accurate input and determines fluid
- Decreased venous filling evidenced by individually adequate output daily. volume status
urinary output with normal specific Note physical signs associated to monitor fluid
gravity, stable vital signs, moist with dehydration. volume status
mucus membranes, good skin turgor Discuss signs & symptoms promotes timely
and prompt capillary refill. indicating need for emergent intervention
evaluation and follow-up.
73
Dependent:
Stop fluid loss by administering prevents fluid loss
medications for diarrhea/fever
as ordered
Administer fluids and for electrolytes
electrolytes as ordered replacement
Establish 24-hour fluid
replacement needs and routes prevents peaks and
to be used as ordered. valleys in fluid level
74
2nd Priority
Name: Jon Snow
Nursing Diagnosis: Diarrhea related to gastrointestinal irritation
Figure 29.
Description of stool as At the end of the 12-hour shift,

verbalized by the mother the clients mother will be able to Observe stools for volume, To note for
verbalize understanding of causative frequency and characteristics. unusualities
factors and rationale for treatment Auscultate abdomen For presence,
regimen and demonstrate location and
appropriate behavior to assist with characteristics of
Objective: resolution of causative factors such bowel sounds
as breast care. Review results of laboratory To determine the
- Hyperactive bowel testing. causal factor and
sounds Long term: treatment
- At least three loose Note reports for absent Sign of dehydration
liquid stools per day At the end of the 2-day duty, the urination. Child needs urgent
client will be able to re-establish and Question parents about child treatment for
maintain normal pattern of bowel crying without tears, fever, dehydration
functioning. decreased urination and no wet
diapers for 6-8 hours. To determine the
Weight the infants diaper amount of output
and fluid
replacement needs
75
Dependent:
To decrease
Administer antidiarrheal gastrointestinal
medications, as indicated motility.
To maintain
Administer enteral and hydration
parenteral fluids, as indicated
76
3rd Priority
Name: Jon Snow
Nursing Diagnosis: Imbalanced Nutrition: less than body requirements related to difficulty absorbing nutrients.
Figure 30.
Not applicable for the client At the end of the 12-hour shift, Assess drug interactions and May affect food
and cannot be determined by the clients mother will be able to disease effects absorption
the mother. verbalize understanding of Assess weight. To establish baseline
causative factors when known and parameters
necessary interventions and Auscultate bowel sounds. To determine bowel
demonstrate behaviors to regain motility
and maintain the childs Evaluate total daily breast Reveals possible cause
Objective: appropriate weight by milk intake. of malnutrition
breastfeeding per demand. Weight regularly. To monitor
Body weight 20% or effectiveness of efforts
more under ideal To increase food intake
Loss of weight Long term: Promote breastfeeding per
Hyperactive bowel After the shift, the client will be demand.
sounds; diarrhea able to demonstrate progressive
Abnormal laboratory weight gain and display
studies normalization of laboratory values
and be free of signs of
malnutrition. To know the treatment
Dependent: and prevents
77
Assist in treating or managing suspected factors to
underlying causative factors. take in.
78
4th Priority
Name: Jon Snow
Nursing Diagnosis: Ineffective Airway Clearance related to excessive mucus
Figure 31.
Not applicable for the At the end of the 12-hour shift, Note respiratory rate, depth, This provides insights
client and cannot be the clients mother will be able to use of accessory muscles, into the work of
determined by the mother. verbalize understanding of causative pursed lip breathing and breathing and
factors and appropriate interventions. areas of pallor and cyanosis adequacy of alveolar
ventilation
Auscultate breath sounds, Abnormal breath
note areas of sounds are indicative
decreased/adventitious of numerous problems
Objective: Long term: breath sounds as well as and must be evaluated
fremitus. for further
Adventitious breath At the end of the 2-day duty, the intervention.
sounds client will be able to demonstrate Note the character and This affects the ability
Cough ineffective improved ventilation and adequate effectiveness of the cough to clear airways of
Changes in oxygenation of tissues by ABGs mechanism. secretions.
respiratory rate within clients usual parameters and Monitor vital signs and Vital signs are
Restless absence of symptoms of respiratory cardiac rhythm. impacted by changes
cyanosis distress. in oxygenation.
To determine
oxygenation and levels
79
Evaluate pulse oximetry and of carbon dioxide
capnography. retention.
It may occur in a long-
term oxygen therapy.
Monitor for carbon dioxide For mobilization of
narcosis. secretions.
Maintain adequate input and

output but avoid fluid To reduce irritant
overload. effect of dust and
chemicals on airways.
Keep environment allergen For improving stamina
and pollutant free. and reducing the work
of breathing.
Emphasize the importance of

nutrition. To clear or maintain
open airway.
To aid oxygen
Dependent: inhalation.
Provide airway adjuncts and
suction, as indicated.
Provide supplemental oxygen To avoid depressant

at lowest concentration effects on respiratory
indicated by laboratory functioning.
results and client symptoms Generally used to
and situation. prevent and control
symptoms, reduce
Use sedation judiciously. frequency and severity
of exacerbations.
Administer medications as
indicated.
80
5th Priority
Name: Jon Snow
Nursing Diagnosis: Impaired skin integrity related to surgery.
Figure 32.
Not applicable for the client At the end of the 12-hour shift, the Inspect the affected To monitor progress of
and cannot be determined by clients mother will be able to participate skin area, noting the wound
the mother. in prevention measures and treatments. redness, swelling and
capillary blanching and
Long term: refill.
Protect area by use of To avoid further
At the end of the 2-day shift, infants foam padding or lamb injury
surgical opening maintains it appropriate wool.
Objective: size for a desired colostomy and will have Keep the area clean To assist bodys
increased granulation tissue with absence and dry. natural process of
Disruption of skin of rashes and lesions. repair.
surface Use appropriate barrier To protect the wound
Disruption of skin dressings and drainage and/or surrounding
layers appliances. tissues.
Maintain appropriate Moisture potentiates
moisture environment. healing.
Assist the mother in
understanding and
81
following medical Enhances
regimen. commitment to plan,
Emphasize importance optimizing outcomes.
of proper fit of clothing To reduce sensation.
Dependent:
Obtain specimen from

drainage when To determine
appropriate for culture appropriate therapy.
and sensitivity.
82
6th Priority
Name: Jon Snow
Nursing Diagnosis: Delayed development related to inadequate nutrition.
Figure 33.
After the 12-hour shift, clients Determine existing conditions To know the causative
Not applicable for mother will be able to verbalize contributing to the delay. factor.
the client and understanding of age-appropriate Identify present growth
cannot be expectations and identify the risk factors age/stage. Provides baseline for
determined by the for developmental delay. identification needs.
mother. Review expectations for current
height/weight percentile. To determine the degree
Long term: Record height/weight over of deviation
After the 2-day shift, clients mother time.
will be able to formulate plans for Monitor growth and To determine trends
Objective: prevention of developmental deviation development factors
Altered and initiate interventions changes periodically. To evaluate effectiveness
physical promoting appropriate development. Evaluate progress on continual of interventions.
growth basis To increase complexity of
Flat affect Avoid blame when discussing tasks.
Listlessness contributing factors. Blame engenders
Decreased negative feelings and
responses does nothing to
Sleep Note chronological age and contribute to solution of
disturbances review expectations for the situation.
83
normal development at this Helps determine
age. developmental
Encourage setting of short- expectations.
term realistic goals for
achieving developmental Small incremental steps
potential. are often easier to deal
with.
Dependent:
Consult professional resources.
To formulate plan and

address specific needs
for intervention.
84
7th Priority
Name: Jon Snow
Nursing Diagnosis: Risk for infection related to surgery.
Figure 34.
Not applicable After the 12-hour shift, clients Assess for the presence These affects the
mother will be able to verbalize of underlying disease, clients infection
understanding of the causative lifestyle, nutritional status, worsen or
factor and identify interventions to status, skin trauma and
demands time for
prevent or reduce risk of infection. environmental exposure.
Observe for changes in healing.
Objective: Long term: skin color and warmth
at the colostomy. It could be signs of
Opening in the abdomen Clients mother will be able to Instruct the clients developing localized
lower right quadrant demonstrate techniques and lifestyle mother to wash hands. infection.
Damaged tissue changes to promote safe
environment. Client will achieve
A first-line defence
afebrile state. Provide clean, well-
ventilated environment. against healthcare-
Change dressing, as associated infections.
indicated, using proper Reduce risk for
technique. infection.
Maintain adequate
hydration.
85
Instruct the clients To avoid microbial
mother to protect the multiplication in the
integrity of the skin, area.
care of lesions, and
To avoid bladder
prevention of spread of
infection. distention.
To prevent more
Dependent: harm and infection.
Administer/monitor To determine
medication regimen, as effectiveness of
indicated.
therapy.
Administer prophylactic
antibiotics and To prevent further
immunizations, as infection.
indicated.
86
ACTUAL
NURSING CARE
PLANS
1. Fluid Volume Deficit related to hypotonic dehydration.

2. Diarrhea related to gastrointestinal irritation.
3. Imbalanced Nutrition: less than body requirements related to difficulty absorbing nutrients.
4. Ineffective Airway Clearance related to excessive mucus.
5. Impaired Skin Integrity related to surgery.
6. Delayed Development related to inadequate nutrition.
7. Risk for Infection related to surgery.
87
1st Priority
Name: Jon Snow
Nursing Diagnosis: Fluid Volume Deficit related to hypotonic dehydration
Figure 35.
Assessment Objectives Interventions Rationale Evaluation

Subjective: Short term: Independent: Clients vital
Assessed vital signs, changes of vital signs during the
Naga-suka na sya ug At the end of the noting rapid signs are shift were stable,
gikalibanga, as verbalized by 12-hour shift, the heartbeat and associated with had good skin
the clients mother. clients mother will be thread peripheral fluid volume loss turgor, moist mucus
able to verbalize pulses. membranes and
understanding of Observed urinary determines fluid prompted capillary
causative factors and output and note the volume status refill. Clients mother
Objectives: purpose of individual color. to evaluate bodys was able to verbalize
therapeutic Reviewed laboratory response to fluid understanding of the
Episodes of vomiting interventions and data. loss condition and was
Prolonged diarrhea medications and Encouraged mother provision for able to demonstrate
Dry skin demonstrate for breastfeeding per increase fluid behaviours such as
Pale and dry oral behaviours to monitor demand. intake monitoring the urine
mucous membrane and correct deficit, as Maintain accurate output, its colour
Poor skin turgor indicated. input and output and such and
Sunken eyeballs daily. determines fluid initiatively provide
Sunken fontanels Note physical signs volume status breastfeed timely per
associated with demand.
Dry lips
dehydration. to monitor fluid
Weak peripheral pulse
Long term: volume status
88
With LBM Discuss signs &
Watery stool After the shift, symptoms indicating
the client will be able need for emergent promotes timely
to maintain fluid evaluation and intervention
volume at a follow-up.
functional level as Dependent:
evidenced by Stop fluid loss by
individually adequate administering
urinary output with medications for
normal specific diarrhea/fever as prevents fluid loss
gravity, stable vital ordered
signs, moist mucus Administer fluids
membranes, good and electrolytes as
skin turgor and ordered for electrolytes
prompt capillary Establish 24-hour replacement
refill. fluid replacement
needs and routes to prevents peaks and
be used as ordered. valleys in fluid level
89
2nd Priority
Name: Jon Snow
Nursing Diagnosis: Diarrhea related to gastrointestinal irritation.
Figure 36.
Subjective: Short term: Independent: The clients mother
was able to
Naga-suka na sya ug At the end of the Observed stools for To note for verbalize
gikalibanga, as verbalized by 12-hour shift, the volume, frequency unusualities understanding of
the clients mother. clients mother will be and characteristics. the condition and
able to verbalize Auscultated abdomen For presence, the rationales for
understanding of location and treatment regimen.
causative factors and characteristics of She was also able
rationale for treatment Reviewed results of bowel sounds to demonstrate
regimen and laboratory testing. To determine the breast care as an
demonstrate appropriate causal factor and appropriate
Objective: behaviour to assist with Noted reports for treatment behaviour for
resolution of causative absent urination. Sign of dehydration preparation for
5x watery yellowish factors such as breast Child needs urgent breastfeeding.
stool a day care. Questioned parents treatment for
Hyperactive bowel about child crying dehydration
sounds: Long term: without tears, fever,
25 clicks/min at every decreased urination
quadrant After the shift, the and no wet diapers for
client will be able to re- 6-8 hours. To determine the
establish and maintain Weighted the infants amount of output
diaper
90
normal pattern of bowel and fluid
functioning. replacement needs
Dependent: To maintain
Administered E-zinc hydration.
drops 0.5 ml OD
To decrease
Administered D5IMB gastrointestinal
2 bottles 500 cc @ motility.
20cc/hour
91
3rd Priority
Name: Jon Snow
Nursing Diagnosis: Imbalanced Nutrition: less than body requirements related to difficulty absorbing nutrients.
Figure 37.
Subjective: Short term: Independent: The clients
mother was able to
Not applicable to the client At the end of the 12- Assessed drug May affect food verbalize
and cannot be determined by hour shift, the clients interactions and absorption understanding of
the mother. mother will be able to disease effects the condition and
verbalize understanding Auscultated bowel To determine bowel demonstrated
of causative factors sounds. motility change of behavior
when known and Evaluated total daily Reveals possible towards the child
necessary interventions milk intake. cause of by initiatively
and demonstrate malnutrition breastfeeding per
behaviors to regain and demand.
maintain the childs Promoted milk feeding To increase food
appropriate weight by per demand. intake
breastfeeding per
demand.
Dependent:
Assisted in treating or
managing underlying To know the
Objective: causative factors by treatment and
Long term: administering prevents suspected
diarrhea lactobacillus factors to take in.
92
small from expected At the end of the acidophilos and
age: month, the client will be famotidine
weight able to demonstrate
3.5kgs progressive weight gain
height 46 and display
cm normalization of
physical development laboratory values and be
inconsistent with age free of signs of
Hyperactive bowel malnutrition.
sounds:
25 clicks/min at
every quadrant
93
4th Priority
Name: Jon Snow
Nursing Diagnosis: Ineffective Airway Clearance related to excessive mucus
Figure 38.
mother was able to
Not applicable by the At the end of the 12- Noted respiratory rate, This provides verbalize
client and cannot be hour shift, the clients depth, use of accessory insights into the understanding of
determined by the mother will be able to muscles, pursed lip work of breathing the condition and
mother. verbalize understanding of breathing and areas of and adequacy of demonstrated
causative factors and pallor and cyanosis alveolar ventilation appropriate
appropriate interventions. Abnormal breath interventions
Auscultated breath sounds are towards the infant
sounds, note areas of indicative of
decreased/adventitious numerous
Objective: Long term: breath sounds as well problems and
as fremitus. must be evaluated
Restless At the end of the 2-day for further
Irritable duty, the client will be able intervention.
Pallor to demonstrate improved This affects the
Respiratory rate: ventilation and adequate ability to clear
50cpm oxygenation of tissues by Noted the character airways of
Fast breathing ABGs within clients usual and effectiveness of the secretions.
Tachypnea parameters and absence of cough mechanism. Vital signs are
Cough noted symptoms of respiratory impacted by
distress.
94
Ronchi Monitored vital signs changes in
and cardiac rhythm. oxygenation.
To reduce irritant
effect of dust and
chemicals on
Kept environment airways.
allergen and pollutant For improving
free. stamina and
reducing the work
of breathing.
Emphasize the Generally used to
importance of prevent and
nutrition. control symptoms,
reduce frequency
Dependent: and severity of
Administered exacerbations.
salbutamol sulfate as
ordered.
95
5th Priority
Name: Jon Snow
Nursing Diagnosis: Impaired skin integrity related to surgery.
Figure 39.
mother was able to
Not applicable for the At the end of the 12-hour Inspected the To monitor progress participate in
client and cannot be shift, the clients mother will be affected skin area, of the wound prevention
determined by the able to participate in prevention noting redness, measures and
mother. measures and treatments. swelling and treatments.
capillary blanching
Long term: and refill. To avoid further
Protected area by injury
At the end of the 2-day shift, use of foam
infants wound retains its padding or lamb
appropriate size for a desired wool. To assist bodys
Objective: colostomy and will have Kept the area clean natural process of
increased granulation tissue and dry. repair.
Opening in the with absence of rashes and To protect the
abdomen lower lesions. Used appropriate wound and/or
right quadrant barrier dressings surrounding
Damaged tissue and drainage tissues.
Skin and tissue appliances. Moisture
color changes: Maintained potentiates healing.
Red appropriate
96
Rashes moisture
Lesions environment.
Enhances
Assisted the mother commitment to
in understanding plan, optimizing
and following outcomes.
medical regimen.
Emphasized To reduce
importance of sensation.
proper fit of
clothing
97
6th Priority
Name: Jon Snow
Nursing Diagnosis: Delayed development related to inadequate nutrition.
Figure 40.
After the 12-hour shift, clients Determined existing To know the causative
Not applicable for mother will be able to verbalize conditions contributing to the factor.
the client and cannot understanding of age-appropriate delay.
be determined by the expectations and identify the risk Identified present growth Provides baseline for
mother. factors for developmental delay. age/stage. identification needs.
Reviewed expectations for To determine the degree

Long term: current height/weight of deviation
After the 2-day shift, clients mother percentile.
Objective: will be able to formulate plans for Recorded height/weight over To determine trends
Altered prevention of developmental deviation time.
physical and initiate interventions changes Monitored growth and To evaluate effectiveness
growth promoting appropriate development. development factors of interventions.
Flat affect periodically.
Small from To increase complexity of
expected age: Evaluated progress on tasks.
weight continual basis Blame engenders
Avoided blame when negative feelings and
3.5kgs discussing contributing does nothing to
factors. contribute to solution of
the situation.
98
height
46 Helps determine
cm Note chronological age and developmental
Physical review expectations for expectations.
development normal development at this
inconsistent age. Small incremental steps
with age are often easier to deal
Encourage setting of short- with.
term realistic goals for
achieving developmental
potential.
99
7th Priority
Name: Jon Snow
Nursing Diagnosis: Risk for infection related to surgery.
Figure 41.

Subjective: Short term: Independent: Clients
mother was able
Not applicable to the After the 12-hour shift, Assessed for the These affects the to verbalize
client and cannot be clients mother will be able to presence of clients infection understanding of
determined by the verbalize understanding of the underlying disease, status, worsen or normal growth
mother. causative factor and identify lifestyle, nutritional and development
demands time for
interventions to prevent or status, skin of a child and
reduce risk of infection. trauma and healing. identified the risk
environmental factors for
Long term: exposure. developmental
Observed for It could be signs of delay.
Objective: After the 2-day shift, changes in skin developing localized
clients mother will be able to color and warmth infection.
Colostomy in the demonstrate techniques and at the colostomy.
A first-line defense
abdomen lower lifestyle changes to promote Instructed the
right quadrant safe environment. Client will clients mother to against healthcare-
Damaged tissue achieve afebrile state. wash hands. associated
infections.
100
Provided clean, Reduce risk for
well-ventilated infection.
environment. To avoid microbial
Changed dressing,
multiplication in
as indicated, using
proper technique. the area.
Maintained
adequate To avoid bladder
hydration. distention.
Instructed the
clients mother to To prevent more
protect the integrity
harm and infection.
of the skin, care of
lesions, and
prevention of
spread of infection.
101

Nursing Care Plans

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Nursing Care Plans

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NURSING CARE

1. Fluid Volume Deficit related to hypotonic dehydration.

Name: Jaun Turtola

Admitting Physician: Dr. Sansa Stark

Name: Jon Snow

Admitting Physician: Dr. Sansa Stark

Nursing Diagnosis: Diarrhea related to gastrointestinal irritation

Description of stool as At the end of the 12-hour shift,

Name: Jon Snow

Admitting Physician: Dr. Sansa Stark

Name: Jon Snow

Admitting Physician: Dr. Sansa Stark

Nursing Diagnosis: Ineffective Airway Clearance related to excessive mucus

Maintain adequate input and

Emphasize the importance of

Provide supplemental oxygen To avoid depressant

Name: Jon Snow

Admitting Physician: Dr. Sansa Stark

Nursing Diagnosis: Impaired skin integrity related to surgery.

Obtain specimen from

Name: Jon Snow

Admitting Physician: Dr. Sansa Stark

Nursing Diagnosis: Delayed development related to inadequate nutrition.

To formulate plan and

Name: Jon Snow

Admitting Physician: Dr. Sansa Stark

Nursing Diagnosis: Risk for infection related to surgery.

1. Fluid Volume Deficit related to hypotonic dehydration.

Name: Jon Snow

Admitting Physician: Dr. Sansa Stark

Nursing Diagnosis: Fluid Volume Deficit related to hypotonic dehydration

Assessment Objectives Interventions Rationale Evaluation

Name: Jon Snow

Admitting Physician: Dr. Sansa Stark

Nursing Diagnosis: Diarrhea related to gastrointestinal irritation.

Name: Jon Snow

Admitting Physician: Dr. Sansa Stark

Name: Jon Snow

Admitting Physician: Dr. Sansa Stark

Nursing Diagnosis: Ineffective Airway Clearance related to excessive mucus

Name: Jon Snow

Admitting Physician: Dr. Sansa Stark

Nursing Diagnosis: Impaired skin integrity related to surgery.

Name: Jon Snow

Admitting Physician: Dr. Sansa Stark

Nursing Diagnosis: Delayed development related to inadequate nutrition.

Reviewed expectations for To determine the degree

Name: Jon Snow

Admitting Physician: Dr. Sansa Stark

Nursing Diagnosis: Risk for infection related to surgery.

Assessment Objectives Interventions Rationale Evaluation

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