VI.
NURSING CARE PLAN
ASSESSMENT DATA
(Subjective & Objective Cues)
 Subjective:
 “ …. Gamay ra akong
ma-ihi…” as verbalized
by the patient.
 Objective:
 Edema
 Decreased Hb (8.4) /Hct
(26.2)
 Change in mental status:
restless
 Abnormal increase of
abdominal girth (77cm)
NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
Excess fluid volume Short-term Goals: Independent: Short-term
related to accumulation of Goals:
fluids in the body After 3 hours of 1. Elevate edematous extremities, change
secondary to acute thorough nursing position frequently. Goals met. After
glomerulonephritis intervention, the R: To reduce tissue pressure and risk of 3 hours of
skin breakdown.
patient will be able to: thorough
nursing
a. Gradually excrete
2. Assist and/or encourage client to turn to intervention, the
excessive fluid sides every 2 hours. patient was be
through urination. R: it aids in the mobilization of fluids to
able to gradually
easily excrete through urination. excrete
b. Demonstrate
excessive fluid
behaviors that 3. Allow client to hear running water.
would help in through
excreting R: to promote diuresis urination and
excessive fluids in demonstrated
4. Apply hot and cold compress on the behaviors that
the body.
client’s bladder (just above symphisis would help in
pubis). excreting
excessive fluids
Long- term Goals: R: to stimulate urination.
in the body.
After 2 days of 5. Encourage bed rest if ascites is
Long- term
thorough nursing present.
Goals:
intervention, the client
R: May promote recumbency-induced
will be able to: Goals met. After
diuresis
2 days of
a. Excrete
thorough
VI. NURSING CARE PLAN
completely Dependent : nursing
excessive fluids intervention, the
as manifested by 1. Administer diuretic (furosemide 20 client was be
the absence of mg IVTT every 8 hours; able to excrete
edema. spironolactone 25 mg 1 tab BID), as completely
ordered excessive fluids
b. Improve the as manifested
distended R: To increase water excretion.
by the absence
abdominal girth 2. Administer albumin 20% IVTT for 30 of edema and
from 77cm to minutes every 12hours improved the
67cms. distended
R: because it helps in the shifting of
abdominal girth
fluids from ISC to IVC.
from 77cm to
67cms.
 VI. NURSING CARE PLAN
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective Cues)

 Subjective Ineffective Breathing Short Term Goals: Independent: Short-term

“ gahangakon ko ug galisod ko Pattern related to
ug ginhawa usahay, “ as accumulation of fluid in After 15 min. of nursing
the peritoneal cavity interventions, the patient
verbalized by the patient.
secondary to Ascites will be able to:
a. Improve
 Objective respiratory rate
from 32cpm to 30
- Increase respiratory rate cpm.
of 32 cpm (tachypneic) b. Demonstrate and
participate on the
- Abnormal increase of treatment given to
abdominal girth of 77cms relieve the condition.
c. Improve the
- Restless client’s behavior
from restless to
responsive by
answering
questions that are
being asked.
Long-Term Goals:
After 1 day of thorough
nursing intervention, the
client will be able to:
a. achieve and
maintain normal
Goals:
1. Assist client in proper deep
breathing exercises. Goals met.After
R: To promote good lung expansion. 15 min. of
nursing
2. Position client in Semi-fowler’s interventions,
position. Elevating the head of bed. the patient was
R: To prevent compression of the able to Improve
diaphragm by allowing the organs in respiratory rate
the peritoneal cavity to lower down. from 32cpm to
30 cpm,
3. Encourage adequate rest periods demonstrated and
between activities. participated on the
R: To avoid overexertion. treatment given to
relieve the
4. Instruct client and/or significant condition and
others not to allow client wear tight improved the
dresses. client’s behavior
R: to promote proper lung expansion from restless to
thus, proper breathing. responsive by
answering
Dependent: questions that
are being
3. Administer diuretic (furosemide 20 asked.
mg IVTT every 8 hours;
spironolactone 25 mg 1 tab BID), as
ordered Long-Term
Goals:
 VI. NURSING CARE PLAN
range of R: To increase water excretion. Goals partially
respiration (15 – met. After 1 day
22cpm) 1. Administer albumin 20% IVTT for 30 of thorough
b. Improve the minutes every 12hours nursing
distended intervention, the
abdominal girth R: because it helps in the shifting of client was able
from 77cm to fluids from ISC to IVC. to improve the
67cms. distended
abdominal girth
from 77cm to
67cms but fails
to achieve and
maintain normal
range of
respiration (15 –
22cpm).

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION

(Subjective & Objective Cues)
 Subjective
“ Luya man ko ug dali ra ko
kapuyon, “ as verbalized by the
patient.
 Objective:
- Abnormal decrease of
RBC 2.96
- Abnormal decrease of
hemoglobin 7.6
- Abnormal decrease of
hematocrit 23.4
- Pale conjunctivae
- Pallor skin
- Restless
- Weak peripheral pulses
VI. NURSING CARE PLAN
(Problem and Etiology) OBJECTIVES RATIONALE
Ineffective Tissue Short –Term Goals: Independent: Short-Term
perfusion(peripheral) Goals.
related to decreased After 2hrs. of nursing 1. Assist patient in ambulation.
hemoglobin concentration interventions, the patient R: To promote venous return. Goals met After
secondary to anemia will be able to: 2hrs. of nursing
2. Inform the patient not to stand/sit for
interventions,
long periods.
R: Prevent venous stasis. the patient was
a. Participate and
demonstrate various be able to
ways to achieve 3. Assist patient in passive or active participate and
effective tissue range-of-motion. demonstrate
perfusion. R: To allow circulation. various ways to
achieve
b. Improve the 4. Turn to side every 2 hrs.
effective tissue
client’s behavior from R: to allow proper blood circulation
perfusion and
restless to
responsive by improved the
answering questions Dependent: client’s behavior
that are being asked. from restless to
1. Administer Packed RBC 450ml for 4
responsive by
– 6 hours, as ordered.
R: To enhance oxygen carrying capacity answering
of the body. questions that
are being
asked.
 VI. NURSING CARE PLAN
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective Cues)

Deficient Diversional After 35 minutes of Independent: Goals were met.

Subjective: Activity related to fatigue nursing interventions,
and malaise. the patient will be able > Acknowledge reality of situation and After 35 minutes
“Laay kaayo magpuyo diri sa to: feelings of the client of nursing
hospital ma’am, gusto na bia *To establish therapeutic relationship interventions,
gusto na ko makigdula sa ako > validate reality of the patient was
mga amigo,” as verbalized by environmental > Review history of activity/hobby able to:
the patient. deprivation. preferences and possible modifications.
> validate
Objective: > note impact of illness > Provide for physical as well as reality of
on lifestyle. diversional activities. environmental
> restless deprivation.
> bored > Encourage mix of desired
> Over eating activities/stimuli (music, story books). > note impact
*Activities need to be personally of illness on
meaningful for patient to derive the most lifestyle.
enjoyment.

Collaborative:

Involve occupational therapist as

appropriate.
*To help identify specific activities
to individual situation.
 VI. NURSING CARE PLAN
ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective Cues)

 Subjectve: Activity Intolerance (Level Short-term Goals: Independent: Short-Term

1) related to imbalance After 15minutes of Goals.
“gahangakon ko basta grabeh between oxygen supply thorough nursing 1. Position client in Semi-fowler’s position.
ang dula” as verbalized by the and demand secondary to intervention, the client R: to promote proper lung expansion. Goals met. After
patient anemia will be able to: 15minutes of
a Improve his respiration 2. Assist client during ambulation. thorough
 Objective: from 32 cpm to 30 cpm. R: to promote circulation nursing
b. Demonstrate intervention, the
- Abnormal decrease of responsiveness by 3. Encourage rest periods fro client and client was able
RBC 2.96 answering questions. avoid exertion on unnecessary to improve his
- Abnormal decrease of c. verbalize the activity activities. respiration from
hemoglobin 7.6 intolerance R: to conserve energy consumption. 32 cpm to 30
- Abnormal decrease of Long-Term Goals: cpm and
hematocrit 23.4 After 8 hours of thorough 4. Listen to the client’s verbalization demonstrated
- pale skin nursing intervention, the about the problem responsiveness
- restlessness client will be able to: R: it will encourage verbalization of by answering
- increase respiration rate feelings. questions and
of 32cpm (tachypneic) a. achieve verbalized the
and Dependent: activity
maintain intolerance.
normal 1. Administer Packed RBC 450ml for 4 Long-Term
range of – 6 hours, as ordered. Goals:
respiration R: To enhance oxygen carrying capacity
(15 – Goals partially met.
of the body. After 8 hours of
22cpm)
b. Ambulate thorough nursing
independe intervention, the
client was able to
ntly without
problems ambulate
in independently
 VI. NURSING CARE PLAN
respiration. without
problems in
respiration.
But failed to
achieve and
maintain normal
range of respiration
(15 – 22cpm).

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective Cues)
 VI. NURSING CARE PLAN
Risk Factors: Risk for Constipation Short-Term Goals: Independent: Short-Term
related to irregular After 45 minutes of Goals:
- Two days without defecation habits thorough nursing 1. Encourage client to increase fiber intake Goals met. After
defecation intervention, the client in his diet. 45 minutes of
- Restless will be able to: R: to improve consistency of stool and thorough
- Decrease bowel sounds a. Gradually facilitate passage through colon. nursing
(3 counts) defecate feces intervention, the
within the body. 2. Promote adequate fluid intake. client was be
b. Improve client’s R: to promote soft stool and stimulate able to gradually
status from bowel activity. defecate feces
restless to within the body,
responsive. 4. Assist client in doing Range of improved
c. Improve bowel Motion. client’s status
sounds from 3 R: to stimulate contraction of the from restless to
counts to 5 intestines. responsive and
counts. improved bowel
Long-Term Goals: 5. Encourage client on frequent sounds from 3
After 1 day of thorough ambulation; counts to 5
nursing intervention, the R: this will promote peristaltic counts.
client will be able to; movement. Long-term
a. Maintain bowel Goals:
habit in Dependent: Goals partially
accordance to his met. After 1 day
time preference. 1. Administer laxative (senna concentrates, of thorough
b. Maintain bowel PRN), as ordered. nursing
sounds within the R: to soften the stool thus, promote intervention, the
normal range. defecation. client was able
to Maintain
bowel sounds
within the
normal range
but failed to
maintain bowel
 VI. NURSING CARE PLAN
habit in
accordance to
his time
preference.

ASSESSMENT DATA NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS AND EVALUATION
(Problem and Etiology) OBJECTIVES RATIONALE
(Subjective & Objective Cues)

Acute pain related to After 1 hour of nursing Independent: Goals were met.
Subjective: inflammation of the renal interventions, the patient
cortex secondary to acute will be able to: > observe nonverbal pain behavior After 1 hour of
“sakit diri dapit sa hawak…” glomerulonephrtis. R: observation may not be congruent with nursing
as verbalized by the patient. > demonstrate verbal reports interventions,
nonpharmalogical the patient was
- Pain scale of 6/10 methods that provide >provide comfort measures, quiet able to:
relief environment and calm activities
Objective: R: to promote nonpharmacological pain >demonstrate
> improve restlessness management nonpharmalogic
> restless >verbalize the decrease > encourage use of relaxation techniques al methods that
> muscle guarding of pain from 6 to 3 scale such as focus ed breathing and imaging provide relief
> facial grimace whenever the R: to distract attention and reduce tension
location of pain is touched. > improve
> .review procedures and tell patent when restlessness
VI. NURSING CARE PLAN
treatment may cause pain. >verbalize the
R: to reduce concern of the unknown and decrease of
associated muscle tension. pain from 6 to 3
scale

Collaborative:

Involve occupational therapist as

appropriate.
*To help identify specific activities
to individual situation.