Possible Nursing Diagnosis for patient with Fever

1. Hyperthermia related to lower respiratory tract infection.

2. Imbalanced Nutrition: Less Than Body Requirements related to Inability to digest foods
3. Fluid volume deficit related to inadequate intake of fluids.
4. Disturbed Sleep Pattern related to fever.
5. Activity intolerance related to general weakness
6. Self-care deficit: Bathing / Hygiene related to weakness
 Assessment Nursing Goal Planning Rationale/Scientific Implementation Evaluation
Diagnosis Principles
SUBJECTIVE DATA Hyperthermia Patient will Provide comfortable To make the client
maintain bed and position comfortable
related to lower
Patient says that “I am normal
respiratory tract body Check vital signs q4h To know the conditions of
having fever since 4
temperature. vital organs
infection as
days, feeling weak, Provide calm and cool
Patient maintains
evidenced by environment Helps to take adequate rest
breathlessness and
normal body
elevated body
cough since 3 days”. Switch on the fan Body heat loss by
temperature as
temperature, convection
Open the windows evidenced by
OBJECTIVE DATA tachycardia,
Good circulation of fresh Body temperature –
tachypnoea, air helps in body heat loss
 Body
by convection 96.80F
dry lips, fatigue
temperature Encourage for plenty
Pulse – 78 bt/mt
and weakness. of oral fluids Heat loss encouraged by
100.4 f
0
conduction Respiration – 18
 Pulse 88 bt/mt Advice the client to
br/mt
wear cotton clothes Heat loss encouraged by
 Respiration
conduction
28br/mt Apply tepid sponging
Heat loss encouraged by
 Cough with
conduction.
sputum
Administer Tab. Antipyretics works on
 Tachycardia, Paracetamol 500mg as hypothalamus and
 Tachypnoea, per order. regulates the body
 Dry lips, temperature.

 Fatigue and Antibiotics control the

Administer antibiotic growth of microorganism
 Weakness as per order in the body which helps
for maintaining normal
body temperature.
 Possible Nursing Diagnosis for patient with Fever
1. Hyperthermia related to lower respiratory tract infection.
2. Imbalanced Nutrition: Less Than Body Requirements related to Inability to digest foods
3. Fluid volume deficit related to inadequate intake of fluids.
4. Disturbed Sleep Pattern related to fever.
5. Activity intolerance related to general weakness
6. Self-care deficit: Bathing / Hygiene related to weakness

1. Nursing Diagnosis: Hyperthermia related to lower respiratory tract infection as evidenced by elevated body temperature, tachycardia, tachypnoea, dry lips,
fatigue and weakness.
Goal: Patient will maintain normal body temperature.

Nursing Interventions Rationale/Scientific Principle

- Provide comfortable bed and position To make the client comfortable
- Check vital signs q4h To know the conditions of vital organs
- Provide calm and cool environment Helps to take adequate rest
- Switch on the fan Body heat loss by convection
- Open the windows Good circulation of fresh air helps in body heat loss by convection
- Encourage for plenty of oral fluids Heat loss encouraged by conduction
- Advice the client to wear cotton clothes Heat loss encouraged by conduction
- Apply tepid sponging Heat loss encouraged by conduction.
- Administer Tab. Paracetamol 500mg as per order. Antipyretics works on hypothalamus and regulates the body temperature.
- Administer antibiotic as per order. Antibiotics control the growth of microorganism in the body which helps for maintaining
normal body temperature.
2. Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to increased metabolic needs and Inability to digest foods as evidenced by
refuse to take fluid and food, reported lack of interest in food, altered taste sensation.
Goal: Patient will maintain normal nutritional pattern.

Nursing Interventions Rationale/Scientific Principle

Assess the nutritional status of the client To know the general condition of the client
Check the body weight of the patient To know the nutritional status of a client
Assess patient likes and dislikes To improve the intake of food and fluids
Provide high calorie, easily digestible and palatable diet Cellular metabolism is greatly increased during fever and to meet increased O2
consumption by the body tissues
Provide small, bland and frequent diet To enhance easy digestion
Encourage for plenty of oral fluids To prevent dehydration and to eliminate waste products
Serve food attractively In order to stimulate appetite
Encourage the client to take fruits To provide vitamins, minerals and also to help in evacuating the bowels regularly
Provide frequent mouth care To minimize the effect of coated tongue and make the client to eat food
Avoid procedures before meals/food To enhance the food intake even though appetite may be slow to return
Maintain I/O chart To prevent and diagnose dehydration earlier
Administer I.V fluids as per order. To prevent dehydration
3. Nursing Diagnosis: Fluid volume deficit related to inadequate intake of fluids and fever as evidenced by poor intake, poor skin turgor, dried lips and oral
mucus membrane.

Goal: Patient will maintain normal fluid volume.

Nursing Interventions Rationale/Scientific Principle

Assess vital signs Elevated temperature/prolonged fever increases metabolic rate and fluid loss through
evaporation. Reduction in circulating volume reduces BP, initiating compensatory
mechanisms of tachycardia to improve cardiac output and increase systemic BP
Palpate peripheral pulses Weak, easily obliterated pulses suggest hypovolemia
Assess thirst, skin turgor, moisture of mucous membranes – lips, Indirect indicators of adequacy of fluid volume
tongue
Note reports of nausea/vomiting Presence of these symptoms reduces oral intake
Weight the client Provides information about adequacy of fluid volume and replacement needs
Encourage to take oral fluids atleast 2500ml/day Meets basic fluid needs, reducing dehydration
Observe the colour and character of urine Provides information about adequacy of fluid volume and replacement needs
Monitor I/O chart Provides information about adequacy of fluid volume and replacement needs
Administer Antipyretics and antiemetic medication as per order It helps in reducing the fluid losses
Provide supplemental IV fluids as necessary In presence of reduced intake/excessive loss, use of parenteral route may correct/prevent
deficiency
4. Nursing Diagnosis: Disturbed Sleep Pattern related to fever as evidenced by verbalisation or interrupted sleep, not feeling as well rested and lethargy.

Goal: Patient will maintain normal sleep pattern

Nursing Interventions Rationale/Scientific Principle

Assess the usual sleep habits and changes are occurring Determines need for action and helps identify appropriate interventions
Provide comfortable bedding and some of own possessions. Eg. Increases comfort for sleep as well as physiologic/psychologic support
Pillow
Provide back care with massage before bedtime Promotes relaxing and smoothing effect
Provide warm glass of milk before bedtime. Milk has soporific qualities, enhancing synthesis of serotonin, a neurotransmitter that
helps patient fall asleep faster and sleep longer
Instruct in relaxation measures Helps to induce sleep
Provide calm and cool environment Provide atmosphere comfort to sleep
Reduce bright lightings Provide atmosphere comfort to sleep
Encourage position of comfort Repositioning alters areas of pressure and promotes rest
Avoid interruptions when possible (awakening for medications or Uninterrupted sleep is more restful, and patient may be unable to return to sleep when
therapies) wakened.
Administer sedatives as per order. Given to help patient sleep/rest during transition period from home to new setting.
5. Nursing Diagnosis: Activity intolerance related to general weakness as evidenced by verbal reports of weakness, fatigue, dull and tired.

Goal: Patient will maintain normal activities

Nursing Interventions Rationale/Scientific Principle

Evaluate patient’s response to activity Establishes patient capabilities/needs and facilitates choice of interventions
Note reports of weakness, fatigue Establishes patient capabilities/needs and facilitates choice of interventions
Provide calm and quiet environment Reduces excess stimulation, promoting rest.
Provide uninterrupted resting periods Uninterrupted sleep is more restful
Encourage to involve in diversional activities – newspaper Reduces excess stimulation, promoting rest
reading.
Explain importance of rest in treatment plan Bedrest in acute phase reduces the metabolic demands, thus conserving energy for
healing.
Assist the position to assume comfortable position for rest and Promotes rest
sleep
Assist for self-care activities Maximizes available energy for self-care tasks
Provide for progressive increase in activities during recovery Minimizes exhaustion and helps to balance the demand
phase
Provide high calorie, small and easily digestible diet Maximise the level of energy
6. Nursing Diagnosis: Self-care deficit: Bathing / Hygiene related to weakness as evidenced by inability to manage ADLs, unkempt appearance

Goal: Patient will maintain adequate self-care abilities

Nursing Interventions Rationale/Scientific Principle

Determine the current capabilities Identifies need for/level of interventions required
Involve the patient in formulation of plan of care at level of Enhances sense of control and aids in cooperation and development of independence
ability
Encourage for self-care Doing for oneself enhances feeling of self-worth, promotes independence, and sense of
control decreases feelings of helplessness.
Provide and promote privacy Reluctance of participate in care or perform activities in presence of others
Assist for mouth care To maintain general cleanliness
Assist for partial bath To maintain general cleanliness
Assist for Combing hair To maintain general cleanliness
Possible nursing Diagnosis for patient with Typhoid Fever

1. Ineffective Breathing Pattern related to: the imbalance of oxygen supply to the needs, dyspnea.

2. Hyperthermia related to the inflammatory process typhi salmonella germs.

3. Acute Pain (abdomen) related to the inflammatory process.

4. Disturbed Sleep Pattern related to pain, fever.

5. Imbalanced Nutrition, Less Than Body Requirements related to inadequate intake.

6. Risk for Fluid Volume Deficit related to inadequate intake and increased body temperature.

7. Altered Bowel Elimination related to constipation.

8. Impaired Physical Mobility related to intake of weakness.

9. Self-Care Deficit : Bathing / Hygiene related to weakness.

10. Anxiety: parents related to lack of knowledge about the disease and the (child's) condition.

POSSIBLE NURSING DIAGNOSES FOR UNCONSCIOUS PATIENT

1. Ineffective airway clearance related to altered level of consciousness

2. Risk for injury related to decreased level of consciousness.
3. Risk for impaired skin integrity related to immobility
4. Impaired urinary elimination related to impairment in sensing and control.
5. Disturbed sensory perception related to neurologic impairment.
6. Interrupted family process related to health crisis.
7. Risk for impaired nutritional status related to altered level of consciousness.
 POSSIBLE NURSING DIAGNOSES FOR FRACTURE PATIENT

1. Risk for Trauma

2. Acute Pain
3. Risk for Peripheral Neurovascular Dysfunction
4. Risk for Impaired Gas Exchange
5. Impaired Physical Mobility
6. Impaired Skin Integrity
7. Risk for Infection
8. Deficient Knowledge

POSSIBLE NURSING DIAGNOSES FOR PATIENT WITH DYSPNOEA

.
1. Ineffective airway clearance related to trachea bronchial inflammation as evidenced by abnormal breath sounds, dyspnoea, and ineffective cough
without sputum.
2. Impaired gas exchange related to alveolar capillary membrane changes as evidenced by dyspnoea, tachycardia and restlessness
3. Activity intolerance related to imbalance between oxygen supply and demand as evidenced by exertional dyspnoea, tachycardia in response to activity,
verbal reports of weakness, fatigue and exhaustion.
4. Altered nutrition less than body requirements related to dyspnoeic episode
5. Risk for fluid volume deficit related to decreased fluid intake
6. Knowledge deficit regarding disease condition, and treatment needs

POSSIBLE NURSING DIAGNOSES FOR PATIENT WITH PARALYSIS

Paraplegia is the loss of movement and sensation in the lower extremities and all or part of the body as a result of injury to the thoracic or medulla. Lumbar or
sacral spinal nerve roots. (Smeilzer, Suzanne C., et al. 2001: 2230).
Nursing Diagnosis and Interventions for Paraplegia
Nursing Diagnosis 1. : Impaired physical mobility related to neurons damage, sensory and motor function.
Goal: Improving mobility.
Expected outcomes: Maintaining the position of the function evidenced by the absence of contractures, foot drop, increasing the strength of the sick body /
compensation, demonstrate techniques / behaviours enabling re-enact activities.
Interventions:
  Assess the functions of sensory and motor patients every 4 hours.
 Change the patient's position every two hours by taking into account the stability and comfort of the patient's body.
 Give retaining board on the patient's foot.
 Use muscle orthopedic, circulation, hand splints.
 Perform passive ROM after 48-72 after injury 4-5 times / day.
 Monitor pain and fatigue in patients.
 Consult physiotherapy to exercise and muscle use as splints.
Rationale:
 Assigning capabilities and limitations of the patient every 4 hours.
 Preventing pressure sores.
 For prevent drop.
 Prevent contractures.
 Increase stimulation and prevent contractures.
 Showed the presence of excessive activity.
 Provide appropriate inducement.
Nursing Diagnosis 2. Risk for Impaired skin integrityrelated to decrease in immobility, decreased sensory function.
Goal: Maintaining the integrity of the skin.
Expected outcomes: The state of the patient's skin intact, free of redness, free from infection on the location of the distressed.
Interventions:
 Assess risk factor for impaired skin integrity.
 Assess the patient's condition every 8 hours.
 Use a special bed.
 Change positions every two hours with anatomical position.
 Maintain the cleanliness and dryness bed and the patient's body.
 Perform special massage / soft over a bony area every two hours with a circular motion.
  Assess the patient's nutritional status and give food with high protein.
 Perform maintenance on the area of skin abrasions / broken every day.
Rationale:
 One of them is immobilization, loss of sensation, incontinence bladder / bowel.
 Earlier prevent the occurrence of pressure sores.
 Reducing the pressure, thereby reducing the risk of pressure sores.
 Depressed area will lead to hypoxia, a change of position improves blood circulation.
 Humid and dirty facilitate the occurrence of skin damage.
 Improve blood circulation.
 Maintain the integrity of the skin and the healing process.
 Accelerate the healing process.
Nursing Diagnosis 3 : Urinary retention related to an inability to urinate spontaneously, interruption spino-thalamicus pathways.
Goal: Increased urinary elimination.
Expected outcomes: The patient can maintain bladder emptying without residues and distension, clear urine, urine culture is negative, fluid intake and output
balance.
Interventions:
 Assess for signs of urinary tract infection.
 Assess fluid intake and output.
 Do the catheter according to the program.
 Instruct the patient to drink 2-3 liters every day.
 Check the patient's bladder every 2 hours.
 Check urinalysis, culture and sensibility.
 Monitor body temperature every 8 hours.
Rationale:
 The effects of the ineffectiveness of the bladder are a urinary tract infection.
  Knowing inadequate kidney function and effective bladder.
 The effects of spinal cord injury are the reflex micturition disorders that need assistance in urine output.
 Prevent urine more concentrated which resulted in the onset of infection.
 Knowing the residue as a result of autonomic hyperreflexia.
 Knowing infection.
 Increased temperature indication of the presence of infection.
Nursing Diagnosis 4: Constipation related to the atony intestine as a result of autonomic disturbances, interruption spinothalamicus pathways.
Goal: Improving bowel function.
Expected outcomes: The patient is free of constipation, stool softening circumstances, shaped.
Interventions:
 Assess the pattern of bowel elimination.
 Give drink 1800 - 2000 ml / day if there are no contraindications.
 Auscultation bowel sounds, assess for abdominal distension.
 Avoid using oral laxatives.
 Mobilize if possible.
 Evaluation and record bleeding at the time of elimination.
 Give suppository according to the program.
 Provide high-fiber diet.
Rationale:
 Determining a change of elimination.
 Prevent constipation.
 Determine the peristaltic movement of the bowel.
 Habitual use of laxatives will occurs dependence.
 Increase the peristaltic movement.
  The possibility of bleeding due to irritation.
 Stool softeners making it easier elimination.
 Fiber increases stool consistency.
Nursing Diagnosis 5. Chronic pain related to treatment, long immobility, psychic injury.
Goal: To provide a sense of comfort: pain.

Expected outcomes: Reported decrease pain / discomfort, identify ways to cope with pain, demonstrate the use of the skills of relaxation and entertainment
activities, according to individual needs.
Interventions:
 Assess for the presence of pain, help the patient identify and quantify pain, such as the location, the type of pain intensity on a scale of 0-1.
 Give comfort measures, for example, a change in position, massage, warm compresses / cold as indicated.
 Encourage the use of relaxation techniques, for example, guidance imagination visualization, deep breathing exercises.
 Collaboration administration of drugs according to indications, muscle relaxants, analgesics; anti-anxiety.
Rationale:
 Patients usually report pain above the level of injury, for example; chest / back or the possibility of a headache than a tool stabilizer.
 Alternative actions to control pain.
 Refocused attention, increase the sense of control, and can improve coping skills.
 Needed to relieve spasms / muscle pain or to eliminate-anxiety and increase the rest.

POSSIBLE NURSING DIAGNOSES FOR PATIENT WITH DEHYDRATION

Nursing Diagnosis for Dehydration

 1. Fluid volume deficit related to excessive output, less intake.
2. Risk for ineffective tissue perfusion related to decreased blood flow.
3. Risk for impaired skin integrity related to decreased skin turgor.
4. Activity intolerance related to physical weakness.
5. Risk for Decreased cardiac output related to a decrease in systemic vascular resistance
Nursing Interventions for Dehydration

1. Fluid volume deficit related to excessive output, less intake.

Goal: adequate fluid volume so that fluid volume deficiency can be overcome.

Expected outcomes:

 Maintain fluid balance.

 Vital signs (pulse = 80-100 beats / min, temperature = 36-37oC)
 Capillary refill less than 3 seconds.
 Akral warm.
 Urine output: 1-2 cc / kg body weight / hour.

Intervention:

 Monitor vital signs, capillary refill, the status of the mucous membranes.
 Discuss strategies to stop vomiting and use of laxatives / diuretics.
 Identification of a plan to increase the optimal fluid balance.
 Assess the results of the test function electrolyte / kidney.
 Give / supervise administration of IV fluids.
 Additional potassium, oral or N as indicated.

2. Risk for ineffective tissue perfusion related to decreased blood flow.

Goal: Maintain / improve tissue perfusion.

Expected outcomes:
  Vital signs are stable BP = 120/80 mmHg, pulse = 80-100 beats / min, no pale skin.
 Warm skin.
 Palpable peripheral pulses.
 Adequate urine output from 0.5 to 1.5 cc / kg / body weight.
 CRT is less than 2 seconds.
 Composmentis consciousness.
 No chest pain.

Intervention:

 Assess changes in the level of consciousness, dizziness complaints.

 Auscultation apical pulse, watch heart rate / rhythm.
 Assess the skin against the cold, pale, sweating.
 Record output and urine specific gravity.
 Observation pale skin, redness, change positions frequently.
 Keep an eye on pulse oximetry.
 Give IV fluids as indicated.

3. Risk for impaired skin integrity related to decreased skin turgor.

Goal: Identify and maintain the skin smooth, supple, intact.

Expected outcomes:

 Good skin turgor, skin intact, no blisters, no redness.

Intervention:

 Observation reddish, pale.

 Use skin cream.
 Discuss the importance of changes in position, it is necessary to maintain the activity.
  Emphasize the importance of nutrient input / adequate fluid.

NURSING DIAGNOSIS: Risk for fluid volume deficit

related to:

1. decreased oral intake associated with anorexia, fatigue, and nausea if present;
2. increased insensible fluid loss associated with diaphoresis and hyperventilation if present;
3. excessive loss of fluid associated with vomiting and/or diarrhea if present with initial infection or as a side effect of antimicrobial therapy.

Desired Outcome

The client will not experience fluid volume deficit as evidenced by:

1. normal skin turgor

2. moist mucous membranes
3. stable weight
4. B/P and pulse within normal range for client and stable with position change
5. usual mental status
6. BUN and Hct within normal range
7. balanced intake and output
8. urine specific gravity within normal range.

Nursing Actions and Selected Purposes/Rationales

1. Assess for and report signs and symptoms of fluid volume deficit:
A. decreased skin turgor
B. dry mucous membranes, thirst
C. sudden weight loss of 2% or greater
D. postural hypotension and/or low B/P
E. weak, rapid pulse
F. neck veins flat when client is supine
G. change in mental status
H. elevated BUN and Hct
I. decrease in urine output with increased specific gravity (reflects an actual rather than a potential fluid volume deficit).
2. Implement measures to prevent or treat fluid volume deficit:
A. perform actions to reduce nausea and vomiting if present (e.g. administer antimicrobial agents with food unless contraindicated,
administer prescribed antiemetics)
B. perform actions to control diarrhea if present (e.g. consult physician about another antimicrobial agent if onset of diarrhea seems related
to initiation of antimicrobial therapy, administer prescribed antidiarrheal agents)
 C. perform actions to reduce fever (see Diagnosis 3, action b) in order to reduce insensible fluid loss associated with diaphoresis and
hyperventilation
D. maintain a fluid intake of at least 2500 ml/day unless contraindicated; if oral intake is inadequate or contraindicated, maintain
intravenous fluid therapy as ordered.

5 Sweat Nursing Diagnosis related to Acute Diarrhea

1. Nursing Diagnosis : Deficient Fluid Volume related to excessive fluid loss through the stool or vomit
characterized by :
Subjective data :
 thirst , nausea , anorexia .
Objective data :
 Inadequacy of oral fluid intake
 Negative balance between intake and output
 Weight loss
 Dry mucous membranes
 Decreased urine output
 Decrease in skin turgor
 Increase in serum sodium
2. Nursing Diagnosis :  Imbalanced Nutrition: less than body requirements related to loss of fluids through diarrhea, inadequate intake is characterized by :
Subjective data :
 Family clients reported a portion of food that is spent.
 Abdominal cramps.
Objective data :
 Weight loss below ideal body weight.
 Upper arm circumference below the ideal.
 Anemic conjunctiva.
 Anorexia.
  Muscle weakness.
 Decrease in serum albumin.
3. Nursing Diagnosis : Risk for infection related to microorganisms that penetrate the gastrointestinal tract .

4. Nursing Diagnosis : Impaired skin integrity : perianal related to irritation from diarrhea characterized by :
Subjective data :
 Changes in comfort : pain, itching
Data obtektif :
 Damage to the skin layer ( dermis ) : lesions and skin irritation due to diaper.
 Perianal area moist and redness.
5. Nursing Diagnosis : Anxiety / fear related to separation from parents , unfamiliar environment , stressful procedure characterized by :
Subjective data :
 Reported feelings of anxiety , fear
Objective data :
 Restless
 Focus on yourself
 Less eye contact
 Choleric
 Tremor
 Facial tension
 Increased respiratory and pulse

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1. a. Define and mention the importance of balance diet (2)

b. Factors to be considered while budgeting food (3)
c. Discuss – Naturopathy diet (3)
d. List down the factors affecting food nutritional value (2)
2. Describe the elements of balanced diet (5)
3. Explain the food groups (5)
4. List down the factors affecting food nutritional value (2)
5. Calculate/Plan for the balanced diet for pre-schooler (5)
6. Menu Planning – Definition, Aims, Principles, meal schedule (5)
1. Nursing Diagnosis: Ineffective airway clearance related to retained secretions/reduced fluid intake/obstruction/tracheobronchial infection
Expected outcome: Patient will maintain patent airway as evidenced by normal lung sounds/thin, white and watery sputum/ respiratory rate with in the
limit of 20-24 breaths/mt in 48 hours.
Nursing interventions
 Assess the lung sounds.
 Assess the respiratory rate
 Administer O2
 Assess the client’s level of .hydration
 Observe the sputum
 Advice to take lot of oral fluids
 Encourage to do deep breathing and coughing exercise q2h
 Provide comfortable position (fowlers)
 Provide chest physiotherapy
 Perform suctioning
 Administer antibiotics

2. Nursing Diagnosis: Impaired/Ineffective breathing pattern related to retained secretions/infection/hypoxia/ineffective cough/shortness of

breath/Broncho constriction and airway irritants
Expected outcome: Patient will maintain normal breathing pattern as evidenced by normal lung sounds/ respiratory rate with in the limit of 20-24
breaths/mt in 48 hours.
Nursing interventions
 Assess the breath sounds.
 Assess the respiratory rate
 Provide comfortable position (fowlers)
 Give steam inhalation
 Encourage to do deep breathing and coughing exercise q2h
 Administer O2
 Perform suctioning
 Administer bronchodilators as per order

3. Nursing Diagnosis: Pain related to drainage tubes/invasive procedures/surgical incision/ upper airway irritation/infection/inflammation/obstruction
Expected outcome: Patient will perceive less pain/ feel comfort as evidenced by verbalisation/facial expression.
Nursing interventions
 Assess the characteristics of pain – location, character, quality, intensity or severity of pain.
 Provide comfortable position
 Give diversional therapy
 Check the position of drainage tube
 Provide psychological support
If post-operative client

 Assess the incision area every 8 hours for redness, warmth over the incision, induration, swelling, separation, and drain
 Assist or turn patient every 2 hours
 Advice the patient to support the incision area while coughing
 Administer analgesics as per order

4. Nursing Diagnosis: Fluid volume deficit related to vomiting/frequent passage of watery stools/altered infusion rate/increased fluid and electrolyte
loss.

Expected outcome: Patient will maintain normal fluid volume as evidenced by maintaining normal serum and urinary values for sodium and
potassium/normal skin turgor/ absence of S/S of dehydration.

Nursing interventions

 Assess the patient condition

 Assess the hydration status
 Check daily weight
 Monitor serum electrolyte levels
 Encourage to take oral fluids
 Administer IV fluids as per order
 Advice to take ORS
 Monitor I/O chart
 Administer antiemetic as per order
5. Nursing Diagnosis: Fluid volume excess related to oedema/altered infusion rate/ retention of sodium and potassium/decreased urine output/ excess
sodium intake.
Expected outcomes: patient will maintain normal fluid volume as evidenced by absence of oedema
Nursing Interventions
 Assess the patient condition
 Assess the hydration status
 Check the weight.
 Monitor serum electrolyte levels
 Elevate the oedematous body part
 Keep the oedematous skin clean and moist
 Limit the fluid intake by prescribed volume
 Monitor strict I/O chart
 Change the position frequently
 Administer diuretics as per order

6. Nursing Diagnosis: Impaired gas exchange related to ventilation-perfusion inequality/chronic inhalation of toxins.
Expected outcomes: Patient will maintain normal gas exchange as evidenced by decrease in dyspnoea/shows an improved expiratory flow rate.
Nursing Interventions
 Assess the respiration – dyspnoea, wheezing, crackles, loosened secretions and anxiety
 Observe the signs and symptoms of hypoxia
 Administer O2
 Administer nebulization
 Analyse arterial blood gases and compare with baseline values
 Encourage patient to do diaphragmatic breathing and effective coughing
 Administer bronchodilators as per order
7. Nursing Diagnosis: Self-care deficit related to fatigue secondary to increased dyspnoea, insufficient ventilation and oxygenation.
Expected outcomes: Patient will maintain /perform normal activities as evidenced by doing daily living activities without assistance.
Nursing Interventions
 Determine the wellness and current capabilities
 Involve the patient in formulation of plan of care at level of ability
 Encourage for self-care
 Provide and promote privacy
 Assist for mouth care
 Assist for partial bath
 Assist for Combing hair
 Provide assistive devices
 Provide adequate rest periods
 Assist the patient to do active and passive exercises
8. Nursing Diagnosis: Impaired skin integrity related to oedema/poor nutritional status/Prolonged bedrest/multiple drains/surgical wound.
Expected outcomes: Patient will maintain normal skin integrity as evidenced by absence of oedema, appearance of healthy skin/demonstrates intact
skin around the colostomy stoma.
Nursing Interventions
 Assess the skin integrity – redness, discolouration, excoriation etc.
 Provide wrinkles free bed
 Provide comfortable position by using comfort measures
 Change the position every 2 hourly
 Give back massage
 Keep the skin clean and moist
 Apply skin moisturizers
 Elevate extremities if there is a edema
 Advice to use non-irritant soap

9. Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to increased metabolic needs and Inability to digest foods as
evidenced by refuse to take fluid and food/ reported lack of interest in food/altered taste sensation/anorexia/gastritis/decreased GI motility.
Expected outcome: Patient will maintain normal nutritional pattern/status as evidenced by adequate intake/ weight gain.

Nursing Interventions
 Assess the nutritional status of the client
 Check the weight of the patient
 Provide clean and pleasant environment
  Assess patient likes and dislikes
 Provide high calorie, easily digestible and palatable diet
 Provide small, bland and frequent diet
 Encourage for plenty of oral fluids
 Encourage the client to take fruits
 Provide frequent mouth care
 Avoid procedures before meals/food
 Maintain I/O chart
 Administer I.V fluids as per order.

10. Nursing Diagnosis: Sleep pattern disturbance related to pain/fear/new environment.

Expected outcome: Patient will maintain normal sleeping pattern as evidenced by verbalisation/ having satisfactory sleeping pattern/looks comfort and
active.

Nursing Interventions
 Assess the sleeping pattern
 Provide comfortable position
 Provide comfortable, wrinkle free bed.
 Provide calm and quiet environment
 Give diversional therapy
 Provide good ventilation
 Advice to avoid day time sleep
 Provide warm milk before bedtime.
 Provide back care/back massage before bed time.
 Provide warm bath
  Provide books to read
 Administer sedatives as per order

11. Nursing Diagnosis: Constipation related to ignoring the urge of defecation secondary to pain during elimination/ depressed gastrointestinal
function.
Expected outcome: Patient will maintain normal elimination pattern as evidenced by verbalisation of less abdominal cramping and pain/ reports
passage of soft and formed stools/ decreased abdominal discomfort.
Nursing Interventions
 Assess the elimination pattern
 Advice to drink more oral fluids
 Advice to take high fiber diet
 Encourage the patient to do exercises
 Tach the patient to make a schedule for meals and the time for defecation
 Administer stool softener as per order
 Administer enema as per order.

12. Nursing Diagnosis: Diarrhoea related to inflammatory process.

Expected outcome: Patient will maintain normal elimination pattern as evidenced by verbalisation that decrease in the frequency of passage/ passing
normal stool.
Nursing Interventions
 Assess the characteristics of the stool
 Assess the hydration status
 Advice to take lot of oral fluids
 Advice to avoid fibre rich diet
 Minto serum electrolyte level
 Keep the environment clean and odour free
  Encourage to take bed rest
 Administer antidiarrheal drug

13. Nursing Diagnosis: Activity intolerance related to fatigue/imbalance between oxygen supply and demand.
Expected outcome: Patient will maintain normal activities as evidenced by participates in self-care activities/reports decreased level of fatigue,
breathlessness, increased level of activity.

Nursing Interventions
 Assess the activity level of the patient
 Assist with self-care activities when patient is fatigued
 Promote independence in self-care activities
 Space activities to promote rest and exercise as tolerated
 Advice the patient to perform mild activities
 Note reports of weakness, fatigue
 Encourage to involve in diversional activities – newspaper reading.
 Explain importance of rest in treatment plan
 Provide high calorie, small and easily digestible diet

14. Nursing Diagnosis: Knowledge deficit regarding treatment/signs and symptoms/follow up care/pre and post-operative care/ diet/exercise/hygienic
measures.
Expected outcome: Patient will gain adequate knowledge as evidenced by verbalisation and answering the questions.
Nursing Interventions
 Assess the knowledge level
 Clear all the doubts of the client about treatment/signs and symptoms/follow up care/pre and post-operative care/ diet/exercise/hygienic measures.
 Explain in simple terms
 Provide adequate information
 15. Nursing Diagnosis: Impaired physical mobility related to pain/use of immobilisation devices/weight bearing limitations/edema.
Expected outcome: Patient will maintain normal physical activity as evidenced by maintains full function of unimpaired extremities/participates in self-
care activities.
Nursing Interventions
 Assess the mobility level
 Assist the patient in daily living activities
 Encourage the patient to do her activities with minimal support
 Provide adequate rest period between the activities
 Encourage the patient to do mild activities
 If metal pins/screws/rods are used – maintain the position

16. Nursing Diagnosis: Fear and Anxiety related to pain/illness/hospitalisation/surgery

Expected outcome: Patient will be free from fear and Anxiety as evidenced by verbalisation/asking doubts/looks comfort

Nursing Interventions

NURSING CARE PLAN FOR FEVER

Hyperthemia

Possible Etiologies: (Related to)

 Exposure to environment with increased temperature; inappropriate clothing

  Dehydration; extreme activity
 Inability or decreased ability to perspire
 Illness or trauma
 Intake of medication; post anesthesia effect
 Increased metabolic rate
 Direct effect of circulating endotoxins on hypothalamus resulting to an altered temperature regulation

Subjective Data:

“I am not feeling well right now. My head is aching and burning as if the steam comes out of my ears periodically.”

Objective Data:

 Flushed skin with body temperature of 38.1ᴼC per axilla

 Respiratory rate of : 21 breaths per minute
 Pulse rate of: 89 beats per minute
 Unstable blood pressure
 Muscle rigidity; chills
 Profuse diaphoresis

Objectives:

 Client will be able to resume and maintain normal body temperature after 4 hours.