NURSING CARE PLAN

Cues Nursing Diagnosis Rationale Nursing Nursing Rationale Expected

Subjective/Objectiv Objectives interventions Outcome
e (Evaluation)
Subjective: Deficient There is After an hour of  Provide  Information Partially Goal Met
Patient’s verbalized knowledge related this presence nurse- patient explanations can decrease
“Tinggal rin ba yung to condition, of knowledge interaction of/reasons for anxiety, After the
apdo ko?” prognosis, deficit due to some the patient will test procedures thereby intervention the
“May mga bawal na treatment, self- unfamiliar informat Verbalize and preparatio reducing patient verbalized
akong kainin?” care, and ion that causes understanding of n needed. sympathetic understanding his
discharge needs some confusion to disease process, prog stimulation. condition.
Objective: the client that needs nosis, and potential  Review
 Asking to be discussed. complications disease proces  Provides
question s/prognosis. knowledge
about his Discuss base from
condition, hospitalization which
treatment, and patient can
and diet. prospective make
treatment as informed
indicated. choices.
Encourage Effective
questions, communicati
expression on and
of concern support at
this time can
diminish
anxiety and
promote
healing
 Review drug
regimen,  Gall stone
possible side often recur,
effects. necessitating
long-term
therapy.
 Instruct patient
to avoid  Prevents/
food/fluids limits
high in fats recurrence of
 (e.g., whole gallbladder
milk, ice attacks.
cream, butter,
fried foods,
nuts, gravies,
pork), gas
producers
(e.g., cabbage,
beans, onions,
carbonated
beverages), or
gastric
irritants(e.g.,
spicy foods,
caffeine,
citrus)

 Suggest
patient limit  Promotes gas
gum chewing, formation,
sucking on which can
straw/hard increase
candy, or gastric
smoking. distension/di
scomfort.
 NURSING CARE PLAN

Cues Nursing Rationale Nursing Nursing Rationale Expected

Subjective/Objective Diagnosis Objectives interventions Outcome
(Evaluation)
Objective: Risk for deficient Fluid volume deficit After 12 hours of  Maintain  To provide Goal Met
VS fluid volume occurs from a loss nursing accurate information
 T: 36.2 (medically of body fluid or the intervention the record of about fluid The patient
 RR: 24 restricted intake) shift of fluids into patient will be I&O, noting status and restored normal
 PR: 78 the third space, or able to output less circulating fluid volume as
 CO2: 98 from are reduced demonstrate than intake, volume evidenced by :
 BP: 110/80 fluid intake. One adequate fluid increased needing - Good skin
 (+) Body common source of balance evidenced urine specific replacement. turgor
weakness fluid loss is nausea by stable vital gravity. - Moist
and signs, moist Assess skin mucous
 (+) Poor skin
vomiting, bleeding mucous and mucous membrane
turgor
and excessive membranes, membranes, s
 (+) dry skin
urination, good skin turgor, peripheral - Vital signs
 (+) dry mouth) gastrointestinal capillary refill, within
pulses, and
tract, polyuria, and individually capillary normal
increased appropriate refill. limits
perspiration. urinary output, - Urine
absence of  Monitor for specific
vomiting. signs and  Prolonged gravity
symptoms of vomiting, within
increased or gastric normal
continued aspiration, range
nausea or and restricted
vomiting, oral intake
abdominal can lead to
cramps, deficits in
weakness, sodium,
twitching, potassium,
seizures, and chloride.
irregular
heart rate,
paresthesia,
hypoactive or
 absent bowel
sounds,
depressed
respirations.

 Eliminate  Reduces
noxious stimulation of
sights or vomiting
smells from center.
environment.

 Perform  Decreases
frequent oral dryness of
hygiene with oral mucous
alcohol-free membranes;
mouthwash; reduces risk
apply of oral
lubricants. bleeding.