Planning Phase

Table 9. Nursing Care Plan (NIC-NOC Format) I

NURSING DIAGNOSIS NURSING OUTCOME CLASSIFICATION (NOC) NURSING INTERVENTION
CLASSIFICATION (NIC)

Imbalanced nutrition: less than body Chosen NOC: Chosen NIC:

requirements related to dietary
restrictions
Subjective Cues:
“May oras na minsan wala akong ganang
kumain, at ang daming hindi ko na pwedeng
kainin. (I have a lot of food restrictions and
oftentimes I experience loss of appetite)” as
verbalized by the client.
Nutritional Status (1004) Nutritional Therapy (1120)
NOC Definition: NIC Definition:
Extent to which nutrient are ingested and absorbed to meet metabolic needs. Administration of food and fluids to support
metabolic process of a patient who is
malnourished or at high risk for becoming
malnourished.
Objective of care:
Demonstrate adequate nutritional intake.

Objective Cues:
 Anemia (Hgb: 98 g/L)
 Fatigue
 Poor Muscle tone
 Initial weight upon entry into
dialysis unit: 57.5kg
 Present weight 51-54kg
 BMI: 19.9 (underweight)

Initial Rating: 2 Outcome Target Rating: 4 Maintain At: Increase To:

Definition of scales Severely Substantially compromised Moderately compromised Mildly compromised Not compromised
compromised 2 3 4 5
1
Outcome Indicator Date Rating Evaluation
08/0 08/0 08/0 08/0 08/1 08/1 08/1 08/1 0814 08/1
5 6 7 9 0 1 2 3 5
Nutrient intake 2 2 2 2 3 3 3 4 4 4 Client is able to meet the adequate nutrient by
consuming a well-balanced meal.
Food intake 2 2 2 2 3 3 4 4 4 4 Consumes food that are of high-biologic protein
value and food rich in fiber.
Fluid intake 2 2 2 2 3 3 3 4 4 4 Adheres to the recommended fluid restriction of
1L per day nephrologist’s orders.

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Energy 2 2 2 2 3 3 3 4 4 4 Verbalized improvement in energy and tolerance
to activities.

Table 10. Activity List (NIC) I

NURSING DIAGNOSIS: Imbalanced nutrition: less than body requirements related to dietary restrictions

Nutrition Management Rationale:

1. Note presence of nausea/anorexia. 1. Symptoms accompany accumulation of endogenous toxins that can alter/reduce
intake and require interventions.

2. Recommend small, frequent meals. Schedule meals according to dialysis 2. Smaller portions may enhance intake. Type of dialysis influences meal patterns,
needs. e.g., patients receiving hemodialysis might not be fed directly before/during
procedure because this can alter fluid removal, and patients undergoing
peritoneal dialysis may be unable to ingest food while abdomen is distended
with Dialysate.

3. Encourage patient to participate in menu planning. 3. May enhance oral intake and promote sense of control/responsibility.

4. Encourage use of herbs/spices, e.g., garlic, onion, pepper, parsley, cilantro, and 4. Adds zest to food to help reduce boredom with diet. Note: some salt substitute
lemon. is high in potassium, and regular soy sauce is high in sodium, and therefore is to
be avoided.

5. Suggest socialization during meals. 5. Provides diversion and promotes social aspects of eating.

6. Encourage frequent mouth care. 6. Reduce undesirable/metallic taste in mouth, which can interfere with food
intake.

7. Provide a balance diet of complex carbohydrates and ordered amount of high- 7. Provides sufficient nutrients to improve energy and prevent muscle wasting
quality protein and essential amino acids. (catabolism); promotes tissue regeneration/healing, and electrolyte balance.
Note: fifty percent of protein intake should be derived from protein sources with
high biological value, such as red meat, poultry, and eggs.
8. Restrict sodium/potassium as indicated, e.g., avoid processed meats and foods,
orange juice, tomato soup. 8. These electrolytes can quickly accumulate, causing fluid retention, weakness,
and potentially lethal cardiac dysrhythmias.

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 Table 11. Nursing Care Plan (NIC-NOC Format) II
NURSING DIAGNOSIS NURSING OUTCOME CLASSIFICATION (NOC) NURSING INTERVENTION
CLASSIFICATION (NIC)

Fluid Volume , excess related to Chosen NOC: Chosen NIC:

Compromised Regulatory Mechanisms Fluid Balance (0601) Fluid/Electrolyte Management (2080)
(Chronic Kidney Disease)

Related Factors: NOC Definition: NIC Definition:

Water balance in the intracellular and extracellular compartments of the body Regulation and prevention of complications
- Excessive fluid and salt intake from altered fluid and/or electrolyte levels.

Subjective Cues:
“Alam ko na may limit ako sa pag-inom ng
tubig pero minsan napaparami ang inom ko
ng tubig lalo na pag mainit ang panahon. (I
know that I have fluid intake limitations but Objective of care:
sometimes I tend to drink a lot most especially Display stable weight, vital signs within patient’s normal range, and absence of
during a hot weather)” as verbalized by the edema.
client.

Objective Cues:
 Oliguria
 Mild bipedal edema
 Fluid intake 2-2.5 liters per day.
 BP changes: elevated BP especially
pre HD (180/100 mmhg)

Initial Rating: 2 Outcome Target Rating: 4 Maintain At:3 Increase To:3

Definition of scales Severely Substantially compromised Moderately compromised Mildly Not compromised
compromised 2 3 compromised 5
1 4
Outcome Indicator Date Rating Evaluation
08/0 08/0 08/0 08/0 08/1 08/1 08/1 08/1 0814 08/1
5 6 7 9 0 1 2 3 5
Blood pressure 2 2 2 2 2 3 3 4 4 4 Blood pressure before each dialysis treatment
is 130 -150 for systolic and 80-90 for diastolic.
Stable body weight 2 2 2 2 2 3 3 4 4 4 Weight gained from previous weight is 0.9-3.5

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 kg.
Peripheral edema 2 2 2 3 3 3 3 3 3 3 No peripheral edema noted.
Skin Turgor 2 2 2 3 3 3 3 4 5 5 Normal skin turgor.

Table 12. Activity List (NIC) II

NURSING DIAGNOSIS: Fluid Volume , excess related to Compromised Regulatory Mechanisms (Chronic Kidney Disease)

Fluid/Electrolyte Management Rationale:

1. Weigh before and after every hemodialysis treatment session, on same scale, 1. Body weight is best monitor with fluid status. A weight gain or more than
with same equipment and clothing. 0.5kg/day suggest fluid retention.

2. Asses fluid status: 2. Assessment provides baseline and ongoing database for monitoring changes and
a. Daily weight evaluating interventions.
b. Intake and output balance
c. Skin turgor and presence of edema
d. Distention of neck veins
e. Blood pressure, pulse rate and rhythm
f. Respiratory rate and effort

3. Limit fluid intake to prescribed volume. 3. Fluid restriction will be determined on basis of weight, urine output, and
response to therapy.

4. Identify potential sources of fluid: 4. Unrecognized sources of excess fluid may be identified.
a. Medications and fluids used to take or administer medications oral
and intravenous
b. Foods

5. Explain to patient and significant others rationale for fluid restriction. 5. Understanding promotes patient and family cooperation with fluid restrictions.

6. Assess level of consciousness; investigate changes in mentation, presence of 6. May reflect fluid shifts, accumulation of toxins, acidosis, electrolyte
restlessness. imbalances, or developing hypoxia.

7. Administer medications as indicated: Antihypertensives, e.g., Clonidine 7. May be given to treat hypertension by counteracting effects of decrease renal
(Catapress) blood flow and/or circulating volume overload.

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 8. Encourage frequent oral hygiene. 8. Oral hygiene minimizes dryness of oral mucous membranes.
Table 13. Nursing Care Plan (NIC-NOC Format) III
NURSING DIAGNOSIS NURSING OUTCOME CLASSIFICATION (NOC) NURSING INTERVENTION
CLASSIFICATION (NIC)

Impaired physical mobility related to Chosen NOC: Chosen NIC:

pain on both knees Mobility (0208) Body Mechanic Promotion (0140)

Subjective Cues: NOC Definition: NIC Definition:

“Minsan nahihirapan talaga akong gumalaw Ability to move purposefully in own environment independently with or Facilitating a patient or a group of patients in the
lalo na pag masakit ang mga tuhud ko. without assistive device. use of posture and movement in daily activities to
(Sometimes I have difficulty in doing Performance of physical activities with vigor. prevent fatigue and musculoskeletal strain or
physical activities because my knees are in injury.
pain)” as verbalized by the client.
Objective of care:
Objective Cues: Attain highest degree of mobility possible within confines of disease.
 Increased pulse Maintain muscle strength and joint ROM.
 Elevated blood uric acid Carry out mobility regimen together with/without assistance of family members.
 Mild swelling of both knees
 Barthel Index of ADL score:
75/100 (moderate dependency)
Initial Rating: 2 Outcome Target Rating: 4 Maintain At: Increase To:
Definition of scales Severely Substantially compromised Moderately compromised Mildly compromised Not compromised
compromised 2 3 4 5
1
Outcome Indicator Date Rating Evaluation
08/0 08/0 08/0 08/0 08/1 08/1 08/1 08/1 0814 08/1
5 6 7 9 0 1 2 3 5
Balance 2 2 2 3 3 3 4 4 4 4 Client was able to stand with by supporting his
hands on the chair when transferring from bed to
chair.
Muscle movement 2 2 2 3 3 4 4 4 4 4 Client can tolerate gradual increase in exercise
and activity.
Joint movement 2 2 2 3 3 3 4 4 4 4 Client was able to move joint without any
discomforts for a period of time.
Body positioning and performance 2 2 2 3 3 4 4 4 4 4 Client was able to perform proper body
positioning when transferring from any position.
Move with ease 2 2 2 2 3 4 4 4 4 4 Mobility improved when performing planned

58
 activities.

Table 14. Activity List (NIC) III

NURSING DIAGNOSIS: Impaired physical mobility related to pain on both knees

Body Mechanic Promotion Rationale:

1. Assess client’s developmental level, motor skills, ease and capability of 1. To determine presence of characteristics of client’s unique impairment and to
movement, posture and gait. guide choice of interventions.

2. Note factors affecting current situation and potential time involved. 2. Identifies potential impairments and determines type of interventions needed
to provide for client’s safety

3. Monitor nutritional needs as they relate to immobility. 3. Good nutrition also gives required energy for participating in an exercise or
rehabilitative activities.

4. Assess the emotional response to the disability or limitation. 4. Acceptance of temporary or more permanent limitations can vary broadly
between individuals. Each person has his or her personal interpretation of
acceptable quality of life.

5. Encourage independence in mobility by helping to move affected part and 5. This may increase client’s self-esteem as well as increase muscle tone.
perform self-care activities such as feeding, bathing and dressing.

6. Use assistive ambulatory devices. 6. Facilitates ambulation/transfers safely.

7. Prevent contractures. 7. Extremities that are now paralyzed are at risk for becoming contracted; ensure
pillow supports are in place as well as rolled towels and adaptive devices.

8. Provide progressive mobilization to the limits of client’s condition. 8. To prevent further complications.

9. Instruct client and significant others in ROM activities, transfers, mobility 9. Education will enable patient and significant others to prevent any further
regimen. complications.

10. Educate patient to promote self-care. 10. Patients will have a decreased ability to care for self-due to new deficits;
promote confidence and participation in caring for themselves as much as
possible

59
 11. Educate patient in accepting limitations. 11. Let the patient understand and accept his or her limitations and abilities.
Assistance, on the other hand, needs to be balanced to prevent the patient from
being unnecessarily dependent.

12. Give explanation about progressive activity to patient. 12. Providing small, attainable goals helps increase self-confidence and reduces
frustration.

13. Facilitate communication; promote family coping and communication. 13. Having a stroke is a major life event. Roles within families and support systems
may change, especially if the patient played a caregiving role within their
family structure.

Table 15. Nursing Care Plan (NIC-NOC Format) IV

NURSING DIAGNOSIS NURSING OUTCOME CLASSIFICATION (NOC) NURSING INTERVENTION
CLASSIFICATION (NIC)

Fatigue related to anemia and dialysis Chosen NOC: Chosen NIC:

procedure Endurance (0001) Energy Management (0180)

Subjective Cues: NOC Definition: NIC Definition:

“Lagi akong pagod. Nararamdaman ko rin
ito pagkatapos ng dialysis ko. Wala akong
lakas, minsan gusto ko ng matulog at
magpahinga. (I get tired easily. I ‘am
feeling weak after every dialysis session. I
just feel like I just want to rest)” as
verbalized by the client.
Capacity to sustain activity. Regulating energy use to treat or prevent fatigue
and optimize function
Objective of care:
Reports improved sense of energy and participate in desired activities at level of
ability.

Objective Cues:
 Anemia (Hgb: 98 g/L)
 Falls asleep immediately after
cannulation for hemodialysis
treatment
 Fatigue Severity Scale score: 46
( suffering fatigue)

Initial Rating: 2 Outcome Target Rating: 4 Maintain At: Increase To:

Definition of scales Severely Substantially compromised Moderately compromised Mildly compromised Not compromised
compromised 2 3 4 5

60
 1
Outcome Indicator Date Rating Evaluation
08/0 08/0 08/0 08/0 08/1 08/1 08/1 08/1 0814 08/1
5 6 7 9 0 1 2 3 5
Performance of usual routine 2 2 2 3 3 3 4 4 4 4 Demonstrate performance of daily routine with
increased levels of energy.
Physical activity 2 2 2 3 3 4 4 4 4 4 Participate in desired physical activities and
hobbies.
Concentration 2 2 2 2 3 4 4 4 4 4 Reported improved concentration in daily tasks.
Energy restored after rest 2 2 2 2 3 3 3 3 4 4 Reported feeling well rested after taking breaks
from activities.
Exhaustion 2 2 2 3 3 3 4 4 4 4 Reported feeling less exhausted and more
energetic.
Hemoglobin 2 2 2 2 2 2 3 3 3 3 Demonstrated increase in hemoglobin by
compliance with epoietin alpha treatment.

Table 16. Activity List (NIC) IV

NURSING DIAGNOSIS: Fatigue related to anemia and dialysis procedure

Nutrition Management Rationale:

1. Note daily patterns (i.e., peaks/valleys) 1. Helpful in determining pattern/timing of activity.

2. Assist patient to cope with fatigue and manage within individual limits of 2. Enhance commitment to promoting optimal outcomes. Temperature and level of
ability: humidity are known to affect exhaustion.
- Establish realistic activity goals with client.

- Provide environment conductive to relief of fatigue.

3. Discuss with patient the need for activity. Plan schedule with patient and 3. Education may provide motivation to increase activity level even though patient
identify activities that lead to fatigue. may feel too weak initially.

4. Alternate activity with periods of rest/uninterrupted sleep. 4. Prevents excessive fatigue.

5. Administer medication as appropriate: 5. Although EPO is given to increase numbers or RBCs, it is not effective without
- Hormones and supplements as indicated, e.g., erythropoietin iron supplementation.

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 (EPO, epogen) and iron supplements.

Table 17. Nursing Care Plan (NIC-NOC Format) V

NURSING DIAGNOSIS NURSING OUTCOME CLASSIFICATION (NOC) NURSING INTERVENTION
CLASSIFICATION (NIC)

Disturbed sleep pattern related to Chosen NOC: Chosen NIC:

unresolved psychological conflict Anxiety Self-Control (1402) Sleep Enhancement (1850)

Subjective Cues: NOC Definition: NIC Definition:

“Nahihirapan akong matulog, kasi minsan Personal actions to eliminate or reduce feelings of apprehension, tension, or Facilitation of regular sleep/wake cycles.
naiisip ko ang sakit ko, lalo na’t bata pa ang uneasiness from unidentifiable source.
mga anak ko. (I ‘am experiencing trouble in
sleeping, maybe because I ‘am worried
about my illness and how it’s affecting my
family)” as verbalized by the client. Objective of care:
Achieve optimal amounts of sleep as evidence by rested appearance,
Objective Cues: verbalization of feeling rested, and improvement in sleep pattern.
 Frequent yawning
 Fatigue
 Often sleeps late at night
 Average sleeping time 4-5 hours
 Insomnia Severity Index score:
14/28 (Subthreshold insomnia)

Initial Rating: 2 Outcome Target Rating: 4 Maintain At: Increase To:

Definition of scales Never Rarely Demonstrated Sometimes Demonstrated Often Demonstrated Consistently
Demonstrated 2 3 4 Demonstrated
1 5
Outcome Indicator Date Rating Evaluation
08/0 08/0 08/0 08/0 08/1 08/1 08/1 08/1 0814 08/1
5 6 7 9 0 1 2 3 5
Monitors intensity of anxiety 2 2 2 2 3 3 3 4 4 4 Client is aware of the anxiety he feels yet does
not monitor its intensity. After continuous
education of its importance, the client eventually

62
 notes intensity of his anxiety.
Decrease environmental stimuli when 2 2 2 3 3 3 4 4 4 4 Listens to his favorite music and reads pocket
anxious books to decrease environmental stimuli.
Seeks information to reduce anxiety 2 2 2 3 3 3 3 3 4 4 Participates in the discussion in search for
information to lessen anxiety.
Plans coping strategies for stressful 2 2 2 2 3 3 3 4 4 4 Plans with the coping strategies for stressful
situations situations. Including the patient in the planning
phase encourage good compliance.
Uses effective coping strategies 2 2 2 3 3 3 3 3 4 4 With the client’s participation in planning, client
is then able to use effective coping strategies to
manage anxiety.
Uses relaxation techniques to reduce 2 2 2 3 3 3 3 4 4 4 Techniques such as imagery, breathing exercise,
anxiety listening to mellow music contribute to reducing
anxiety that client feels.
Monitors duration of episodes 2 2 3 3 3 3 3 3 4 4 Unaware of the duration of episodes as client
does not monitor them first. Eventually upon
discussing things over with us, client already
monitors duration of anxiety episodes and reports
shorter episodes after 10 days of care.
Maintains role performance 2 2 2 2 3 3 3 3 4 4 Client still maintains his role as a person.
Maintain social relationship 2 2 2 3 3 3 3 4 4 4 His anxiety, however, did not affect his
relationship with other people.
Maintains concentration 2 2 2 3 3 3 3 3 4 4 With the anxiety he felt, he most often loss
concentration in what he does. Upon
verbalization of problems, ways were sought in
collaboration with the nurse and client to find
ways on how to maintain concentration even
when under stress.
Maintains adequate sleep 2 2 2 2 3 3 3 4 4 4 Client, in due course, have already maintains
adequate sleep.
Monitors physical manifestation of anxiety 2 2 2 3 3 3 3 4 4 4 Client experienced easy fatigability when he does
not have enough sleep. He then monitors physical
manifestation of anxiety.
Monitors behavioral manifestation of 2 2 2 3 3 3 3 4 4 4 Often, the client is moody when he lacks sleep.
anxiety He has less concentration especially when doing
something. Along with the physical
manifestations, he also monitors behavioral
manifestation of anxiety.
Controls anxiety response 2 2 2 3 3 3 3 3 4 4 When client feels she cannot handle it anymore,

63
 he just cries. Knowing that anxiety can be
controlled, he then sought after different ways to
manage anxiety and he applies them in his
everyday life.

Table 18. Activity List (NIC) V

NURSING DIAGNOSIS: Disturbed sleep pattern related to unresolved psychological conflict

Sleep Enhancement Rationale:

Ongoing Assessment 1. Sleep patterns are unique to each individual.

1. Assess the past patterns of sleep in normal environment: amount, bedtime
rituals, depth, length, position, aids, and interfering agents.

2. Assess the client’s perception of cause of sleep difficulty and possible 2. For short-term problems, client may have insight into the etiological factors of
relief measures to facilitate treatment. the problem. Knowing the specific etiological factor will guide appropriate
therapy.

3. Identify factors that may facilitate or interfere with normal patterns. 3. Considerable confusion and myths about sleep exist. Knowledge of its role in
the health and wellness and the wide variation among individuals may allay
anxiety, thereby promoting rest and sleep.
Therapeutic Interventions:
4. Instruct the client to follow as consistent a daily schedule for retiring and 4. This promotes regulation of cardiac rhythm and reduces the energy required for
arising as possible. adaptation to changes.

5. Instruct the client to avoid heavy meals, alcohol, caffeine, or smoking 5. Although hunger can also keep one awake, gastric digestion and stimulation
before eating. from caffeine and nicotine can disturb sleep.

6. Instruct the client to avoid large fluid intake before bedtime. 6. This helps client who otherwise may need to void during the night.

7. Increase day time physical activities as indicated, but instruct the client to 7. Activity reduces stress and promotes sleep. However, over fatigue may cause
avoid strenuous activity before bedtime. insomnia.

8. Discourage pattern of daytime naps unless deemed necessary to meet 8. Napping can disrupt normal sleep patterns; however, older people do better with
sleep requirements or if part of one’s usual pattern. frequent naps during the day to counter their shorter nighttime schedules.

9. Suggest use of soporifics such as milk. 9. Milk contains L-tryptophan, which facilitates sleep.

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10. Recommend an environment conducive to sleep or rest. Suggest use of 10. Many people sleep better in cool, dark, quiet environments.
earplugs or eye shades as appropriate.

11. Suggest engaging in relaxation activity before retiring (e.g., warm bath, 11. These activities provide relaxation and distraction to prepare the body and mind
calm music, reading an enjoyable book, relaxation techniques). for sleep.

12. If unable to fall asleep after 30 to 40 minutes, suggest getting out of the 12. The bed should not be associated with wakefulness, TV, watching, or work.
bed and engaging in a relaxing activity.

Education/Continuity of Care 13. This allows client to participate in their care.

13. Teach about: possible cause of sleeping difficulties and optimal ways to
treat them.
14. Non-pharmacologic sleep enhancement techniques can be used throughout a
14. Instruct on non-pharmacological sleep enhancement techniques. lifetime. Pharmacological sleep agents should only be used for a limited time.

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