Nursing Care Plan

Name of the Patient: RR

Medical Diagnosis: Breast CA Stage 4
Nursing Diagnosis: Risk for infection related to frequent vomiting

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Deficient Fluid Volume Short-Term Goal: After 1. Monitor vital signs. -To provide baseline data. Short-Term Goal: After 8
“Nanunuyo na ang related to Dysphagia as 8 hours of nursing hours of nursing
llalamunanan ko…” as evidenced by dry mucous intervention, the client 2. Measure and monitor intake and -To provide baseline data. intervention, the client will
verbalized by the membranes, decrease pulse will be able to maintain output including urine, stool, and be able to maintain fluid
patient. volume, and pressure. fluid volume at vomitus. volume at functional level
functional level with with good mucous
Objective: good mucous membrane, good skin turgor,
→ T= 36.5°C membrane, good skin 3. Assess client’s behaviour and -A person with dehydration may and normal elimination
→weight loss turgor, and normal activity level every shift. develop anorexia, decreased pattern.
→dry lips elimination pattern. activity level and general malaise.
→abnormal color of
urine 4. Compare current weight gain -Daily body weight is best monitor
→hair is dry with admission or previous stated of fluid status. A weight gain of
weight gain. more than 0.5kg/day suggest fluid
retention.

5. Review laboratory results. BUN, -To evaluate degree of fluid excess,

Creatinine and Serum electrolytes. and obtain baseline data.

6. Monitor IV infusion after every -Infusing too rapidly or too slow can
hour. lead to fluid imbalance.

7. Observe skin mucous -To prevent ulcerations.

membranes.

8. Evaluate mental status for -May reflect fluid shifts,

confusion and personality changes. accumulation of toxins, acidosis,
electrolyte imbalance, or
developing hypoxia.
 Nursing Care Plan

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

1. Ascertain understanding of 1. To determine informational
Subjective: “Nahihirapan Risk for imbalance nutrition: Short-Term Goal: After 6 individual nutritional needs. needs of client Short-Term Goal: After 6
ako lumunok less than body requirements hours of nursing hours of nursing
pakiramdam ko ang sikip related to esophageal interventions client will 2. Assess weight, measure or 2. To establish baseline interventions, the client
ng lalamunan ko…” as narrowing secondary to verbalize understanding calculate body fat and muscle parameters. verbalized understanding of
verbalized by the patient. extraluminal compression: of causative factors and mass and other causative factors and
esophageal gastroduodenitis necessary interventions anthropometric necessary interventions to
Objective: to promote optimum measurements. promote optimum nutrition.
→dysphagia nutrition.
→Esophageal Narrowing 3. Observe for absence of 3. Indicates protein-energy Long-Term Goal: After 1-2
(endoscopy) Long-Term Goal: After 1-2 subcutaneous fat and muscle malnutrition. days of nursing
→Esophageal stricture days of nursing wasting, hair loss, fissuring of interventions, the client
(esophagram) interventions client will nail, delayed healing of demonstrated behaviors,
→weight loss from 57kg. be able to demonstrate wounds, gum bleeding or lifestyle changes and was
down to 55kg in 3 days behaviors, lifestyle swollen abdomen. able to regain and maintain
changes to regain and appropriate nutrition intake.
maintain appropriate 4. Auscultate bowel sounds. 4. Auscultation of the abdomen is
nutrition intake. Note for characteristic of stool performed for detection of altered
(color, amount, frequency) bowel sounds, rubs or vascular
bruits.

5. Provide diet modification as 5. Therapeutic diets are also used

indicated. (formula tube by dietitians to either maintain a
feedings, parenteral nutrition healthy lifestyle or improve health.
infusion)

6. Instruct client to avoid 6. Foods that are hard to digest

foods that causes intolerance leads to symptoms such as
or increase gastric motility intestinal gas, abdominal pain or
according to individual needs. diarrhea.

7. Assist with or provide oral 7. To ensure the patients mouth

care before and after meals are cared for.
and at bedtime.

8. Promote adequate and 8. To ensure that there is an

timely fluid intake. adequate body hydration.
 Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: “Nanunuyo na Deficient fluid volume Short-Term Goal: At the end 1. Assess for signs of 1. To determine the cause of Short-Term Goal: At the end
ung lalamunan ko…” as related to fluid loss of the shift, the client will be dehydration including skin pharyngeal pain. This will of the shift, the client was
verbalized by the patient. secondary to vomiting able to reduce vomiting by turgor, oral mucosa etc. provide a data that could be able to reduce vomiting by
promoting an environment used to evaluate the proper promoting an environment
Objective: conducive for doing ADL’s intervention that the client conducive for doing ADL’s
• V/S and improve skin turgor. needs. and improved skin turgor.
T= 36.5
PR= Long-Term Goal: After 1 day 2. Monitor I & O and IV fluids 2. To determine if IV fluid Long-Term Goal: After 1 day
RR= of thorough nursing and electrolyte replacement of thorough nursing
BP= intervention, the client will are needed. intervention, the client was
•pale conjunctiva be able to maintain body 3. Keep a quiet environment able to maintain body fluid
•decreased skin turgor fluid levels and completely and calm activities 3. To reduce stress and levels and completely
• frequent vomiting eliminate occurrence of anxiety. eliminate occurrence of
vomiting. 4. Provide health teachings vomiting.
on avoidance of dehydration. 4. To promote awareness on
related factors.
5. provide frequent oral and
skin care. 5. To prevent injury from
dryness.
6. Promote well ventilated
environment conducive for 6. To avoid the occurrence of
eating. vomiting.

7. Change position
frequently.
8. Administer medication for
vomiting (as ordered)
9. Administer fluids and
electrolytes ( as ordered)
7. To promote proper
circulation of blood, thus,
preventing from fluid deficit.
8. To decrease occurrence of
vomiting.
9. To gradually correct the
deficiency in fluids.