Nursing Care Plan

Problem Identified: Ascites and grade 3 bipedal pitting edema

Nursing Diagnosis: Fluid Volume Excess related to decreased plasma proteins secondary to Miliary Tuberculosis
Cause Analysis: Any process that blocks the flow of the blood causes an increase in hydrostatic pressure. As portal pressure increases, plasma leaks directly from the liver capsule and the
congested portal vein into the peritoneal cavity. Congestion of lymph channels occurs, leading to the leakage of more plasma into the peritoneal cavity. Leading to edema.
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: STO: Independent: STO:
1. Noted presence of medical 1. To assess causative or precipitating
“ Mabigat ang paa at tiyan ko”, as Within 3 days of providing conditions/ situations that potentiates factor. After 3 days of providing
verbalized by the paient nursing care the client will be able fluid excess (e.g, diffuse liver nursing care, the goal was not met.
to decrease her pitting edema parenchymal disease,as shown in the Her bipedal pitting edema was still
from grade 3 to grade 2. ultrasound of the whole abdomen). grade 3.
2. Auscultated lung sounds. 2. For presence of crackles or
congestion.

3. Measured abdominal girth. 3. For changes that may indicate

Objective: increasing fluid retention or edema.
 Grade 3bipedal pitting
edema 4. Instructed SO the need for frequent 4. To prevent stasis and reduce risk of
 Abdominal girth: passive ROM of client and frequent tissue injury.
1st day: 88 cm change of position.
2nd day: 88cm
5. Recorded I/O accurately; calculated 5. To keep monitor closely the fluid
3rd day: 84 cm
24-hour fluid balance. intake and output for the whole day.
 Albumin- 17.37
 X-ray result suggesting left 6. For presence of decubitus/
6. Observed skin and mucous
pleural effusion at the base membranes. ulceration.
And minimal pleural fluid
at left upper lobe 7. Elevated edematous extremities. 7. To reduce tissue pressure and
 Lung sounds: risk of skin breakdown.
1st and 2nd day- (+)
wheezing and crackles Collaborative:
1. To promote elimination of excess
3rd day- (+)wheezing on 1. Administered Furosemide 200 mg
fluid.
both lung fields IVTT now.
2. Administered Aminoleban 500cc @
 Hct-36-38 2. Since she have decreased plasma
20 cc/hour
protein level.

Problem Identified: Anxiety
Nursing Diagnosis: Anxiety related to stress secondary to hospitalizations
Cause Analysis: Anxiety is normal reaction to stress; it is an emotional reaction to the perception of reality that is experience physiologically, psychologically and behaviorally.(Psychaitric Nursing, p. 318)
CUES
Subjective:
“ Nag aalala na ako kasi mtagal
na ako dito sa hospital na
papabayaan ko na ang pag-aaral
ko”, as verbalized by the client.
Objective:
 Worries about hospitalization
 Increased tension
 RR- 35-40 cpm
 HR- 85- 100bpm
OBJECTIVE
STO:
Within 3 days of giving health
teaching and rendering nursing care
the patient will have decreased
anxiety level as evidenced by
appearing relax and report anxiety is
reduced to manageable level.
Nursing Care Plan
INTERVENTIONS
INDEPENDENT:
1. Helped the client to determine
the sources of anxiety. Helped the
client determine the level of
anxiety.
2. Encouraged client to verbalize
feelings & express emotions.
3. Decreased sensory stimulation.
4.Provided support, stayed with
the client, spoke slowly and calmly
and conveyed a sense of caring
and empathy.
5. Allowed the behavior to belong
to the client: didn’t respond
personally.
6. Provided non threatening,
consistent environment /
atmosphere .
RATIONALE EVALUATION
STO:
1. These actions help the client
establish realistic understanding of After 3 days the goal was not
the nature and cause of the met. Client was still anxious.
anxiety. Once the stress is
accurately understood & the client
can readily identify strategies for
coping.
2. Sharing concerns and expressing
emotions can decrease the client’s
feeling being alone or
overwhelmed by stressful
situation.
3. Excessive sensory stimulation
may increase the client’s anxiety.
4.Providing reassuring presence
decreases the client stress of
alones and support the client in
coping
5. The nurse may respond
inappropriately , escalating the
situation to a non therapeutic
interaction.
6. To lessen effect of transmission
of feelings.
 Nursing Care Plan

Problem Identified: Difficulty of sleeping

Nursing Diagnosis: Disturbed Sleep Pattern related to external stimulus: sustained environmental stimulation
Cause Analysis: Environmental stimulus can either promote or hinder sleep. Environmental stimuli such as light, humid room atmosphere, routine hospital activities,
conversation of the staff nurse and other environmental stimuli can hinder sleep especially to hospitalized persons, resulting to altered sleeping pattern in which the
individual experiences a disruption in the amount or quantity of sleep, causing discomfort.
(Fundamentals of Nursing by Kozier and Erb & Nursing diagnosis Handbook By Ackley)

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:
“Gusto kong matulog pero hindi
ako maka tulog”, as verbalized by
the client.
Objective:
 Irritability
 Patient appeared
exhausted/weak during
the day
 Appeared anxious
 Decreased attention span
STO:
Within 3 days of
rendering effective nursing
interventions, the patient
will be able to report
improvement on sleep/rest
pattern as evidenced by
increased hours of sleep
from 5-6 hours to 8-10
hours.
INDEPENDENT
1. Assessed patient’s sleep
pattern and usual bedtime
rituals and incorporate this
to the plan of care.
2. Observed client’s
medications, diet, and
caffeine intake.
3. Provided measures to
assist with sleep such as
quiet time before bed or a
back massage.
4. Encouraged client to
develop a bedtime rituals
that include quite activities
such as watching
television,
5. Suggested by abstaining
from daytime naps
STO:
1. Usual sleep patterns are
individual, data collected After 3 days of rendering
through a comprehensive effective nursing interventions,
and holistic assessment are goal was met. The patient was able
needed to determine the to sleep for 8 hours straight.
etiology of the disturbance
2. Difficulty sleeping can be a
side effect of some
medications; caffeine
intake can interfere with
sleep.
3. Simple measures can
increase quality of sleep;
research on back massage
has shown it to be
effective.
4. Good bedtime rituals will
promote or induce sleep.
5. To preventing impairment
of ability to sleep at night.

Reference: Nursing Diagnosis Handbook by Ackley 2nd Edition ; Manual of Nursing Diagnosis by Doenges
 Nursing Care Plans
Problem Identified: inability to perform ADL’s
Nursing Diagnosis: Self care deficit: bathing/ hygiene, dressing/ grooming, feeding, toileting related to fatigue
Cause Analysis: Mechanical insufficiency in breathing leading to hypoxia and decrease in O2 to the muscles, decreasing level of spontaneous physical activity causing
fatigue. Fatigue would lead to decrease ability of the individual to carry out ADL’s.. (Fundamentals of Nursing by Kozier p.698 and 1133)
CUES OBJECTIVE INTERVENTIONS
Subjective: STO: INDEPENDENT:
“ Hindi ko na naaalagaan ang Within 3 days of rendering 1. Assessed abilities and
sarili ko dahil nanghihina na ang nursing care the client will be able level of deficit for
katawan ko”, as verbalized by the to perform self care activities performing ADL’s
client. within level of own ability such as
combing her hair. 2. Observed for signs of
readiness to increase
the amount of self-care.
3. Monitor all self-care
activities to determine
energy expenditure and
Objective: activity tolerance,
-Pt is dependent on her SO assessed vital signs and
-Muscle grading: observed the client for
Upper extremities- 3 fatigue and
Lower extremities- discouragement.
- Always lying on bed
-Limited movement 4. Assisted patient in
-unable to do ADLs by herself performing ADL.
5. Maintained a supportive,
firm attitude, allow client
sufficient time to
accomplish tasks.
6. Encouraged patient to
do as much possible to
self.
Rationale RATIONALE
STO:
1. Aids in anticipating/ After 3 days of rendering
planning for meeting nursing care the goal was not met.
individual needs. Client was still dependent on SO in
performing self care activities.
2. Revisions of the
functional level status
are necessary to ensure
optimal self-care activity.
3. Adverse signs indicate
the need for more
assistance.
4. Appropriate assistance
prevents client fatigue
and injury.
5. Clients need empathy
and to know caregivers
will be consistent in their
assistance.
6. This maintains functional
capacity and self-
esteem.
 7. Provided positive 7. Enhances sense of self
feedback for efforts and worth, promotes
accomplishments. independence, and
encourages client to
continue endeavors.

Sources: NCP by Doenges et. Al pp 291-292


Problem identified: lack of knowledge
Nursing Diagnosis: Knowledge Deficit related to unfamiliarity with information resources
Cause Analysis: The total range of what has been learned or perceived as true is knowledge. It is accumulated through experience, study, or investigation. Culture, socio
economic factors, age affects knowledge or perception (p39, General Sociology Focus on the Philippines 3rd ed by Panopio, Raymundo, Cordero-MacDonald)
CUES
Subjective:
“ Bakit kaya PTB ang naging
sakit ko gayong pag laki lang
nang tiyan ang problema ko as
verbalized by the client.
Objective:
 always asks questions
regarding present
condition
OBJECTIVE
STO:
INDEPENDENT:
Within 3 days of providing
daily information regarding
present condition the client will
initiate necessary lifestyle
changes and participate in
treatment regimen.
Nursing Care Plan
INTERVENTIONS
1. Assess motivation and
willingness of patient and
care-givers to learn.
2. Determine patient’s
learning style, especially if
patient has learned and
retained new information in
the past.
3. Provide an atmosphere of
respect, openness, trust,
and collaboration.
4. Encourage questions.
5. Encourage repetition of
information or new skill.
6. Assist the learner in
integrating information into
daily life.
RATIONALE EVALUATION
STO:
1. Some patients are ready to After 3 days of providing
learn soon after they are daily information regarding
diagnosed; others cope better
present condition, the goal was
by denying or delaying the
need for instruction. Patients met. Client participated in her
also have a right to refuse treatment regimen.
educational services.
2. Some persons may prefer
written over visual materials,
or they may prefer group
versus individual instruction.
Matching the learner’s
preferred style with the
educational method will
facilitate success in mastery of
knowledge.
3. This is especially important
when providing education to
patients with different values
and beliefs about health and
illness.
4. Learners often feel shy or
embarrassed about asking
questions and often want
permission to ask them.
5. This assists in remembering.
6. This helps learner make
adjustments in daily life that
will result in the desired
change in behavior .
Sources: Nursing Care Plans and Documentation by L. Carpenito; Nursing care plan by M. Doenges; Nursing care planning guide by S. Ultic

Nursing Care Plan

Problem Identified: generalized body weakness

Nursing Diagnosis: Impaired Physical mobility related to decreased muscle strength
Cause Analysis: Mechanical insufficiency in breathing leading to hypoxia and decrease in O2 to the muscles, decreasing level of spontaneous physical activity.Fatigue,
especially chronic fatigue, can seriously impact the ability to function effectively in everyday life. Underlying diseases, disorders or conditions of fatigue can also cause complications.
(http://www.wrongdiagnosis.com/sym/fatigue.htm)

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: STO: INDEPENDENT:
“Nanghihina na ang katawan 1.Noted presence of factors
ko”, as verbalized by the client. Within 3 days of giving health contributing to fatigue(e.Gchronic
teaching and rendering nursing disease)
care the client will be able to 2. Evaluated client’s actual and
perceived limitations or degree of
identify negative factors affecting
deficit in light of usual status.
activity intolerance and eliminate
or reduce their effects when 3. Ascertained ability to stand and
possible and participate willingly in move about and degree of assistance
desired activities. necessary/ use of equipment.
Objective: 4.Provided positive atmosphere , while
 Patient has limited ROM, acknowledging difficulty of the
 grade 3muscle grading on situation for the client .
upper extremities
 grade 3 muscle grading on 5. Planned for maximal activity within
lower extremities the client,s ability .
 exertional discomfort
 Hgb-121-127
 RBC-4.3-4.62 6. Planned for progressive increase of
activity level or participation in
exercise training, as tolerated by
client.
7. Encouraged client to maintain
positive attitude; suggest us of
relaxation techniques, such as
visualization / guided imagery, as
appropriate.
STO:
1. Fatigue affects both the client’s
actul and perceived ability to After 3 days the goal was
participate in activities . only partially met. Client
2. Provides comparative baseline and hesitated in participating on
provides information about needed certain activities, at times.
education or interventions regarding
quality of life.
3. To determine current status and
needs associated with participation in
needed/ desired activities.
4. Helps to minimize frustration and re
channel energy.
5. Promotes the idea of need for or
normalcy of progressive abilities in this
area.
6. Both activity tolerance and health
status may improve with progressive
training.
7. To enhance sense of well-being.

Nursing Care Plan

Problem identified: grade3 bipedal edema and ascites
Nursing Diagnosis: Disturbed body image related to presence of edema and ascites
Cause Analysis: Throughout the lifespan, body image changes as a matter of development, growth and maturation, changes that occur as a result of aging and changes that occur or are imposed as a result
of injury or illness.(Gulanick and Meyer’s.Nursing Care Plans:Nursing Diagnosis and Interventions 6 th ed.(2007) p.21)
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: STO: INDEPENDENT: STO:
1 .Acknowledged and accepted 1. Acceptance of this feeling as a
 “ Mabigat ang paa at tiyan
ko”, as verbalized by the paient
Objective:
 Not touching the body part
 Change in social involvement
 Actual change in structure
 Grade 3bipedal pitting
edema
 Abdominal girth:
1st day: 88 cm
2nd day: 88cm
3rd day: 84 cm
Problem Identified: occasional productive cough
Nursing Diagnosis: Ineffective Airway Clearance related to ineffective cough and fatigue
Cause Analysis: In tuberculosis, the infected lung inflames causing further development of bronchopneumonia where there is exudates formation. REFERENCE: Joyce M. Black, et.al. ,
Medical Surgical Nursing, Clinical Management for Positive Outcomes, 6th edition and Nursing Care plan 10th Edition)
CUES
Subjective:
“ Nahihirapan siyang e –dura
ang plema niya kasi parang
Within 3 days of rendering
nursing intervention the patient
will be able to recognize and
incorporate body image change
into self- concept in accurate
manner without negating self-
esteem.
OBJECTIVES
STO:
Within 3 days of rendering
expression of feelings of frustration,
grief, hostility. Note withdrawn
behavior and use of denial.
2. Was realistic and positive during
treatments in health teaching and
setting goals within limitations.
3. Provided hope within parameters of
individual situation, didn’t give false
reassurance.
4. Gave positive reinforcement of
progress and encourage endeavors
toward attainment of rehabilitation
goals.
5. Encouraged family interaction with
each other and with rehabilitation
team.
6. Encouraged SO to look for support.
Give information about how so can be
helpful to patient.
7. Encouraged patient to look at/
touch affected body part.
Nursing Care Plan
INTERVENTIONS
INDEPENDENT:
1. Assessed cough for effectiveness 1. Consider possible causes for
and productivity ineffective cough (e.g., respiratory
normal response to what has occurred
facilitates resolution. It is not helpful After 3 days, goal was not met
of possible to push patient ready to patient showed low self esteem
deal with situation. Denial maybe regarding present body image.
prolonged and be an adaptive
mechanism because patient is not
ready to cope with personal problems.
2. Enhance trust and rapport between
patient and nurse.
3. Promotes positive attitude and
provides opportunity to set goals and
plan for future based on reality.
4.Words of encouragement can
support development of positive
coping behaviors.
5. Maintain open lines of
communication and provides on
ongoing support for patient and
family.
6. Promotes ventilation of feelings
and allow for more helpful responses
to patient.
7. To begin to incorporate changes in
body image.
RATIONALE EVALUATION
STO:
After 3 days the goal was
nahihirapan siyang huminga”, as
verbalized by the SO.
Objective:
 Occasional productive
cough
 Sputum is yellowish and
slightly sticky
 (+) crackles on both lung
fileds
 (+) wheezing on both lung
fields
 O2 saturation- 80%
effective nursing intervention the
client will be able to mobilize
secretions effectively and airway is
maintained free of secretions, as
evidenced by clear lung sounds.
2. Sent a sputum specimen for
culture and sensitivity as
appropriate.
3. Noted presence of sputum;
assess quality, color, amount, odor,
and consistency.
4. Used positioning (if tolerated,
head of bed at 45 degrees)
5. Maintained planned rest
periods. Promote energy-
conservation techniques.
6.. Demonstrated and taught
coughing, deep breathing, and
splinting techniques.
7. Explained effects of smoking,
including second-hand smoke.
Collaborative:
1. Gave Beradual 1 nebule every 8
hours, Salbutamol 1 nebule every 4
hours, Flixotid 1 nebule every 12
hours
muscle fatigue, severe partially met. Client was able to
bronchospasm, or thick tenacious expectorate a little amount of her
secretions). phlegm but not all.
2. Respiratory infections increase
the work of breathing; antibiotic
treatment is indicated.
3. This may be a result of infection,
A sign of infection is discolored
sputum (no longer clear or white);
an odor may be present.
4. These promote better lung
expansion and improved air
exchange.
5. Fatigue is a contributing factor
to ineffective coughing.
6. Patient will understand the
rationale and appropriate
techniques to keep the airway
clear of secretions.
7. Smoking contributes to
bronchospasm and increased
mucus production in the airways.
1. A bronchodilator is a substance
that dilates the bronchi and
bronchioles, decreasing resistance
in the respiratory airway and
increasing airflow to the lungs.
 Nursing Care Plan
Problem Identified: tachypnea
Nursing Diagnosis: Ineffective Breathing pattern related to inflammation of the infected lung
Cause Analysis: In tuberculosis, the infected lung inflames causing further development of bronchopneumonia where there is exudates formation then obstructs the alveoli and narrowing
of the bronchioles causing impairment in gas exchange of the lungs.( Pathophysiology by Porth and Med Surg by Smeltzer)
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: STO: INDEPENDENT: STO:
“Mabilis ang paghinga ko”, as 1. Assessed respiratory rate and 1. Respiratory rate and rhythm
verbalized by the client. Within 3 days of rendering depth by listening to lung sounds. changes are early warning signs of After 3 days of duty, the goal
 effective nursing care the client
will be able to maintain effective 2. Assessed for dyspnea at rest
breathing pattern as evidenced by versus activity and note changes.
Oxygen saturation above 95 %. 3. Assess ability to clear secretions.
4. Used pulse oximetry to monitor
oxygen saturation and pulse rate.
Objective:
 Tachypnea
 Occasional productive
cough 5. Monitored ABGs as appropriate;
 RR- 35-48cpm note changes.
 Respiratory depth changes
 O2 saturation- 80%
6. Explained use of oxygen therapy,
including the type and use of
equipment and why its
maintenance is important.
COLLABORATIVE:
1. Administered O2 inhalation @ 8
LPM.
2. Gave Beradual 1 nebule every 8
hours, Salbutamol 1 nebule every 4
hours, Flixotid 1 nebule every 12
hours
impending respiratory difficulties. was not met. Clients O2 sat is still
2. Dyspnea that occurs with decreasing at times, especially
activity may indicate activity during 11pm- 7am.
intolerance.
3. The inability to clear secretions
may add to a change in breathing
pattern.
4. Pulse oximetry is a useful tool to
detect changes in oxygenation
early on; however, for CO2 levels,
end tidal CO2 monitoring or arterial
blood gases (ABGs) would need to
be obtained.
5. Increasing PaCO2 and
decreasing PaO2 are signs of
respiratory failure. As the patient
begins to fail, the respiratory rate
decreases and PaCO2 begins to
rise.
6. Issues related to home oxygen
use, storage, and precautions need
to be addressed.
1. The appropriate amount of
oxygen is continuously delivered so
that the patient does not
desaturate.
2.. A bronchodilator is a substance
that dilates the bronchi
andbronchioles, decreasing
resistance in the respiratory airway
and increasing airflow to the lungs.
 Nursing Care Plan

Problem Identified: pain in left lower extremity upon elevation, headache, abdominal tenderness
Nursing Diagnosis: Acute pain related to injuring agents (physical: edematous feet, ascites; chemical:adverse reaction of peptaz medication)
Cause Analysis: Headache is one of the most common side effects of her medication peptaz. Her pain in the left lower extremity is due to prolonged immobilization and presence of grade
3 pitting edema. Her abdominal tenderness is due accumulation of fluids in her abdomen.
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective:
“ Masakit ang ulo ko, tiyan ko
tsaka yong kaliwang paa ko kapag
inaangat siya”, as verbalized by
the client
Pan scale:
headache-4/10, after giving Peptaz
SINUSES-3/10, upon palpation
STOMACH- 2/10, upon movement
Left Lower leg-3/10, upon elevtion
Objective:
 Guarding behavior,
protecting body part
 Self-focused
 Narrowed focus
 RR- 40cpm
 PR- 100bpm
STO:
Within 3 days of rendering
nursing intervention the client will
be able to verbalize reduction of
pain to adequate relief of pain as
evidenced by pain scale from 4/10
to 2/10.
INDEPENDENT:
1. Observed or monitored signs
and symptoms associated with
pain, such as BP, heart rate,
temperature, color and moisture
of skin, restlessness, and ability to
focus.
2. Assessed for probable cause of
pain.
3. Responded immediately to
complaint of pain.
4 Eliminated additional stressors or
sources of discomfort whenever
possible..
5. Provided rest periods to
facilitate comfort, sleep, and
relaxation.
STO:
1. Some people deny the After 3 days the goal was met.
experience of pain when it is Client did not complained of pain
present. Attention to associated anymore.
signs may help the nurse in
evaluating pain.
2. Different etiological factors
respond better to different
therapies.
3. In the midst of painful
experiences a patient’s perception
of time may become distorted.
Prompt responses to complaints
may result in decreased anxiety in
the patient. Demonstrated concern
for patient’s welfare and comfort
fosters the development of a
trusting relationship.
4. Patients may experience an
exaggeration in pain or a
decreased ability to tolerate
painful stimuli if environmental,
intrapersonal, or intrapsychic
factors are further stressing them.
5. The patient’s experiences of pain
may become exaggerated as the
result of fatigue. In a cyclic fashion,
pain may result in fatigue, which
may result in exaggerated pain
and exhaustion. A quiet
environment, a darkened room,
and a disconnected phone are all
measures geared toward
facilitating rest.
 Nursing Care Plan

Problem Identified:ineffective mobilization of sputum/ phlegm

Nursing Diagnosis: Risk for Aspiration related to ineffective mobilization of sputum.
Cause Analysis: When phlegm is not effectively expectorated, especially if it is thick in consistency it could put the person at great risk for aspiration. If swallowed, a foreign object may
become stuck along the gastrointestinal (GI)tract, which can lead to infection or bleeding. (http://www.nlm.nih.gov/medlineplus/ency/article/000036.htm)
 CUES OBJECTIVES INTERVENTIONS
No cues, problems has not STO: INDEPENDENT:
occurred yet. 1 Monitored level of
Within 3 days of rendering consciousness..
nursing care the patient will be
able to maintain patent airway and
will not experience aspiration.
2. Assessed cough and gag
reflexes.
3. Assessed pulmonary status for
clinical evidence of aspiration.
Auscultate breath sounds for
development of crackles and/or
rhonchi.
4. Kept suction setup available (in
both hospital and home settings)
and use as needed.
5. Provided oral care after meals.
6. Explained to patient/caregiver
the need for proper positioning.
7. Instruct on signs and
symptoms of aspiration.
Nursing Care Plan
Problem Identified: skin lesion approximately 2 cm in diameter and reddish in color on sacral area
Nursing Diagnosis: Impaired Skin Integrity related to presence of sacral skin lesion secondary to prolonged bed rest.
Cause Analysis: Normal blood circulation relies on muscular activity. Immobility impedes circulation and diminished the supply of nutrients to specific areas as a result of
breakdown and formation of pressure ulcers can occur. (Fundamentals of Nursing by Kozier p. 1071)
CUES OBJECTIVES INTERVENTIONS
Subjective: STO: INDEPENDENT:
RATIONALE EVALUATION
STO:
1. A decreased level of
consciousness is a prime risk factor After 3 days the goal was
for aspiration. met. Client was not aspirated.
2. A depressed cough or gag
reflex increases the risk of
aspiration.
3. Aspiration of small amounts can
occur without coughing or sudden
onset of respiratory distress,
especially in patients with
decreased levels of consciousness.
4. This is necessary to maintain a
patent airway.
5. This removes residuals and
reduces pocketing of food that can
be later aspirated.
6. This decreases the risk of
aspiration.
7. This aids in appropriately
assessing high-risk situations and
determining when to call for
further evaluation.
RATIONALE EVALUATION
STO:
 “May rashes ako sa may puwet,
kasi yung tita ko hindi marunong
mag linis kapag nag tae ako”, as
verbalized by the client
Objective:
 skin lesion approximately 2
cm in diameter and
reddish in color on sacral
area
 Grade 3 bipedal pitting
edema
Within 3 days of rendering
nursing intervention the clients’
skin lesion will not be worsen as
evidenced by decrease redness
and diameter will not increase in
size.
1. Assessed general condition of
skin.
2. Limited chair sitting to 2 hours at
any one time.
1. Healthy skin varies from
individual to individual, but should After 3 days the goal was not
have good turgor (an indication of met. Pressure ulcer was not
moisture), feel warm and dry to evaluated because client hesitated.
the touch, be free of impairment
(scratches, bruises, excoriation,
rashes), and have quick capillary
refill (<6 seconds).
2. Pressure over sacrum may
exceed 100 mm Hg pressure during
sitting. The pressure necessary to
close skin capillaries is around 32
mm Hg; any pressure greater than
32 mm Hg results in skin ischemia.

3. Encourage use of lift sheets to 3. These measures reduce shearing

move patient in bed and forces on the skin.
discourage patient or caregiver
from elevating HOB repeatedly.

4. Increased tissue perfusion by 4. Massaging reddened area may

massaging around affected area. damage skin further.

5. Elevated lower extremities 5. Enhance venous return,

when sitting. reducing venous stasis/edema.

6.Encouraged continuation of 6. To enhance circulation.

regular exercise program
(assistive)
Nursing Care Plan

Problem Identified: fever

Nursing Diagnosis: Hyperthermia related to illness secondary to Miliary Tuberculosis
Cause Analysis: When you have an infection, the bacteria or virus is thriving in that homeostatic environment and spreading. Your body's reponse is to interupt or alter the
normal homeostatic environment in order to kill or slow down the spread of the infection. Thus the body will temporarly raise your normal body temperature to a
temoperature which it can tolerate but which is outside the parameters for that microorganism.

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: STO: INDEPENDENT: STO:
“ Maginaw ang pakiramdam 1. Monitored client temperature 1. Chills often precede
ko”, as verbalized by the client. Within 8 hours of rendering (degree and pattern), note shaking temperature spikes. After 8 hours the goal was
nursing intervention the client will chills/ profuse diaphoresis. met. Client’s fever was relieved.
be able to be relieved of fever as
evidenced by temperature of 37.2 2. Monitored environmental 2. Room temperature/ number of
and below. temperature, limit/add bed linens blankets should be altered to
as indicated. maintain near- normal body
temperature.
Objective:
 T- 38.7 3. Provided tepid sponge baths, 3. May help reduce fever .use of
 Skin warm to touch avoid use of alcohol. ice water/ alcohol may Cause
 Flushed skin chills, actually elevating
 Tachypnea temperature. In addition, alcohol is
 RR- 48cpm very drying to skin.

COLLABORATIVE:
1. Administered paracetamol 500 1. To relieve fever.
mg 1 tab PRN for fever.