Bulacan State University

COLLEGE OF NURSING
City of Malolos, Bulacan

NURSING CARE PLAN

Patient’s Initial: T.H. Age: 34 y.o Gender: Male Date Handled: _________________

Medical Diagnosis: Cushing Syndrome Chief Complaint: Changes of appearance Clinical Area: __________________

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective:
• Reports weight gain
(particularly through
his midsection), easy
bruising, and edema of
his feet, lower legs, and
hands  - verbalize awareness of
• Has been having
increasing weakness
and insomnia
Objective:
• Physical examination:
BP 150/110; 2+ edema
of lower extremities;
purplish striae on
Risk for excess fluid Short Term Goal: Independent:
volume as evidenced After 8hrs of nursing
by edema of the intervention, the client
extremities. will:
-maintain HR 60 to 100
beats/min.
causative factors and
behaviors essential to
correct fluid excess.
- explain measures that
can be taken to treat or
prevent fluid volume
excess.
 Instruct patient,  Information and
caregiver, and family knowledge about
members regarding condition are vital to
fluid restrictions, as patients who will be co-
appropriate. managing fluids.
 Monitor fluid intake.  This enhances
compliance with the
regimen.
 Administer IV fluids  Administer IV fluids
through an infusion through an infusion
pump, if possible.
pump, if possible.
Short Term Evaluation:
After 8hrs of nursing
intervention, the goals
were met. The client:
-maintained HR 60 to
100 beats/min
-verbalizes awareness
of causative factors and
behaviors essential to
correct fluid excess.
-explains measures that
can be taken to treat or
prevent fluid volume
excess.
abdomen; thin Long Term Goal:  Administer IV fluids  Administer IV fluids Long Term Evaluation:
extremities with thin, After 16hrs of nursing through an infusion through an infusion After 16hrs of nursing
friable skin; severe acne intervention, the client pump, if possible. pump, if possible. intervention, the goals
of the face and neck  will: were met. The client:
• Blood analysis: -have balanced intake -has balanced intake
Glucose 167 mg/dL (9.3 and output and stable and output and stable
mmol/L); white blood weight. weight.
cell (WBC) count Dependent:
-maintain HR 60 to 100 -maintains HR 60 to 100
13,600/µL;  Take diuretics as  Diuretics aids in the
beats/min. beats/min.
lymphocytes 12%; red prescribed. excretion of excess body
blood cell (RBC) count -have clear lung sounds -has clear lung sounds
fluids.
6.0 × 10 as manifested by absence as manifested by
6/µL; K+ 3.2 mEq/L (3.2 of pulmonary crackles.  Elevate edematous  Elevation increases absence of pulmonary
mmol/L) extremities, and handle venous return to the crackles.
with care. heart and, in turn,
decreases edema.
Edematous skin is more
susceptible to injury.

 Educate patient and  Information is key to

family members managing problems.
regarding fluid volume
excess and its causes.

 Explain the need to use  These aids help promote

antiembolic stockings venous return and
or bandages, as minimize fluid
ordered. accumulation in the
extremities.
  Knowledge heightens
 Educate patient and compliance with the
family members the treatment plan.
importance of proper
nutrition, hydration,
and diet modification.