ADVENTIST MEDICAL CENTER COLLEGE

Brgy. San Miguel, Iligan City

SCHOOL OF NURSING

NURSING CARE PLAN

Client Name:
Age: 66 years old

Assessment Nursing Planning Nursing Rationale Evaluation

Data based on Diagnosis (Desired or Interventions
PEROS and Expected
GORDON’S Outcomes)
Subjective Data: Fluid volume STO: Independent: Independent: STO:
“Nikalit lang jud ug excess r/t After 8 hours of 1) Determine or 1) Potential exists for After 8 hours of
kadako iyang tiyan electrolyte nursing estimate the amount of fluid overload due to nursing
ma’am atong imbalance interventions, client fluid intake from all fluid shifts and changes interventions, client
Sabado. Pero wala AEB enlarged will be able to: sources. in electrolyte balance. was able to:
na siya nagsuka” as abdomen - Verbalize 2) Review nutritional 2) Imbalances in these - Verbalize
verbalized by the understanding of issues (e.g., intake of areas are associated understanding of
S/O. individual dietary sodium, potassium). with fluid imbalances. individual dietary
and fluid restrictions 3) Measure abdominal 3) For changes that may and fluid restrictions
Objective Data: - Demonstrate girth. indicate increasing fluid - Demonstrate
- Confusion behaviors to monitor 4) Record I&O retention/edema. behaviors to monitor
- Decreased urinary fluid status and accurately; calculate 4) So that adjustments fluid status and
output reduce recurrence of 24-hour fluid balance. can be made in the reduce recurrence of
- Total I&O fluid excess 5) Elevate edematous following 24-hour fluid excess
- Nonpitting edema extremities and intake if needed.
on both lower LTO: change position 5) To reduce tissue LTO:
extremities After 3 days of frequently. pressure and risk of After 3 days of
- Abdominal girth nursing 6) Place in semi- skin breakdown. nursing
((Day 1) = 98 cm interventions, client Fowler’s position 6) May promote interventions, client
Abdominal Girth will be able to: when at bed rest, as recumbency-induced was able to:
(Day 2) = 91 cm - Stabilize fluid appropriate. diuresis and facilitate - Stabilize fluid
Abdominal Girth volume as evidenced 7) Set an appropriate respiratory effort when volume as evidenced
(Day 3) = 93 cm) by balanced input rate of fluid intake and movement of the by balanced input
- Ileus upon and output and free infusion throughout diaphragm is limited. and output and free
auscultation signs of edema 24-hr period. 7) To prevent signs of edema
- Dullness over exacerbation of excess
percussion Collaborative or fluid volume and to
- Low sodium level Interdisciplinary prevent peaks and
= 116.4 (normal Care: valleys in fluid level.
level should be 135- 1) Administer
148mmol/L) medications as Collaborative or
- Low albumin level ordered. Interdisciplinary
= 28.07 (normal (Human Albumin Care:
level should be 38- 25% q12h) (Lasix 1) To reduce congestion
54g/L) 40mg slow IVTT q8h) and edema.
(Heraclene Forte 3mg
1 cap OD) (NaCl 2
tabs TID)

References: Doenges, M., Moorhouse, M., & Murr, A. (2022). In Nurse's Pocket Guide, Diagnoses, Prioritized Interventions, and
Rationales, 16th ed. (pp. 395-399). Philadelphia: F.A. Davis Company.

Assessment Nursing Planning Nursing Rationale Evaluation

 Data based on Diagnosis (Desired or Interventions
PEROS and Expected
GORDON’S Outcomes)
Subjective Data: Dysfunctional STO: Independent: Independent: STO:
- Reports of gastrointestinal After 8 hours of 1) Note lifestyle. 1) There are issues that STO:
abdominal pain motility r/t nursing 2) Inspect abdomen, can affect GI function After 8 hours of
decrease in interventions, client noting contour. and health. nursing
“Ang problema peristaltic will be able to: 3) Auscultate 2) Distention of bowel interventions, client
ma’am kana ra gyud activity AEB - Verbalize abdomen. may indicate was able to:
iyang tiyan ni dako” absence of understanding of 4) Measure abdominal accumulation of fluids - Verbalize
as verbalized by the BM, and causative factors and girth. and gases formed. understanding of
S/O. abdominal rationale for 5) Note frequency and 3) Hypoactive bowel causative factors and
distention treatment regimen characteristics of sounds may indicate rationale for
Objective Data: - Demonstrate bowel movements. ileus. treatment regimen
- Absence of flatus appropriate 6) Measure GI output 4) To monitor - Demonstrate
until third day behaviors to assist periodically and note development or appropriate
- Constipation/no with resolution of characteristics of progression of behaviors to assist
BM causative factors drainage. distention. with resolution of
- Distended or 7) Manage pain with 5) May reveal an causative factors
enlarged abdomen LTO: nonpharmacological underlying problem or
- NGT open to drain After 3 days of interventions such as effect of pathology. LTO:
with dark green nursing positioning, back rub, 6) To manage fluid After 3 days of
discharges noted interventions, client or heating pad (unless losses and replacement nursing
(Day 1 = 15cc will be able to: contraindicated). needs and electrolyte interventions, client
Day 2 = 315cc - Reestablish and balance. was able to:
Day 3 = ?) maintain normal Collaborative or 7) To enhance muscle - Reestablish and
- Hypoactive bowel pattern of bowel Interdisciplinary relaxation and reduce maintain normal
sounds functioning Care: discomfort. pattern of bowel
1) Maintain GI rest functioning
when indicated – Collaborative or
NPO, fluids only as Interdisciplinary
ordered. Care:
2) Collaborate in 1) To reduce intestinal
 treatment of bloating and risk of
underlying conditions. vomiting.
3) Administer fluids 2) To correct or treat
and electrolytes as disorders associated
indicated. with client’s current GI
4) Administer dysfunction.
medication as ordered 3) To replace losses and
(Fleet Enema) to improve GI
circulation and
function.
4) To reduce risk of GI
dysfunction.

References: Doenges, M., Moorhouse, M., & Murr, A. (2022). In Nurse's Pocket Guide, Diagnoses, Prioritized Interventions, and
Rationales, 16th ed. (pp. 419-425). Philadelphia: F.A. Davis Company.

Assessment Nursing Planning Nursing Rationale Evaluation

Data based on Diagnosis (Desired or Interventions
 PEROS and Expected
GORDON’S Outcomes)
Subjective Data: Impaired STO: Independent: Independent: STO:
“Kapoyan siya ug physical After 4-8 hours of 1) Note factors 1) Identifies potential After 4-8 hours of
tindog” as mobility r/t nursing affecting current impairments and nursing
verbalized by the pain AEB interventions, client situation. determines types of interventions, client
S/O. reports of pain will be able to: 2) Assist with interventions needed to was able to:
when sitting or - Verbalize treatment of provide for client’s - Verbalize
“Kana raman gyud standing up understanding of underlying condition safety. understanding of
iyang sakit sa tiyan and physical situation and causing pain and/or 2) To maximize the situation and
iyang problema” as deconditioning individual treatment dysfunction. potential for mobility individual treatment
verbalized by the regimen and safety 3) Promote comfort and function. regimen and safety
S/O measures measures and provide 3) To enhance ability to measures
- Demonstrate relief of pain. participate in activities. - Demonstrate
“Sakit akong luyo” techniques or 4) Identify energy- 4) Limits fatigue, techniques or
as verbalized by the behaviors that enable conserving techniques maximizing behaviors that enable
client. resumption of for ADLs. participation. resumption of
activities 5) Encourage 5) Enhances self- activities
Objective Data: - Report pain is participation in self- concept and sense of - Report pain is
- Slow movement relieved or care. independence. relieved or
- Needs support controlled controlled
when sitting or Collaborative or Collaborative or
standing LTO: Interdisciplinary Interdisciplinary LTO:
- Weak in After 3 days of Care: Care: After 3 days of
appearance nursing 1) Involve client and 1) Enhances nursing
- Cannot perform interventions, client S/O in care, assisting commitment to plan, interventions, client
ADL’s alone will be able to: them to learn ways of optimizing outcomes. was able to:
- Facial grimace - Participate in managing problems of 2) To permit maximal - Participate in
when moving ADLs and desired immobility. effort and involvement ADLs and desired
- Irritability activities 2) Administer in activity. activities
- Maintain or medications as needed - Maintain or
increase strength and for pain relief. increase strength and
function of affected (Starcox 120mg tab function of affected
 and/or compensatory OD pc breakfast) and/or compensatory
body parts (Algesia 1 tab TID po body parts
RTC)

References: Doenges, M., Moorhouse, M., & Murr, A. (2022). In Nurse's Pocket Guide, Diagnoses, Prioritized Interventions, and
Rationales, 16th ed. (pp. 616-621). Philadelphia: F.A. Davis Company.