Impaired physical mobility of the lower extremity r/t external fixator @ L leg  Breastfeeding Ineffective  Ineffective airway clearance

r/t lung impairment  Impaired skin integrity r/t traction application  Family Nursing Care Plan  Impaired Urinary Elimination r/t oral fluid/solid restriction & sensory motor impairment  Ineffective tissue perfusion related to vasoconstriction of blood vessels  Diarrhea  Chronic Obstructive Pulmonary Disease (COPD)  Fever  TB Meningitis  Pedia TB Meningitis  Ineffective Airway Clearance r/t secretions in the bronchi  Cholecystectomy  Hyperbilirubinemia (Jaundice)  Caesarean Delivery  Potts Disease  Endometrial Cancer  Cholelithiasis  Typhoid Fever  Cholecystectomy (Gallbladder Removal)  Urinary Tract Infection (UTI)

 CEREBROVASCULAR ACCIDENT  Neonatal Pneumonia  Community Acquired Pneumonia  Dengue Fever  Nausea & Vomiting  Appendicitis  Abruptio Placenta  Hyperthyroidism  Anemia  Preterm Labor  Ectopic Pregnancy  Pregnancy Induced Hypertension (PIH; Preeclampsia and Eclampsia)  Placenta Previa  Leptospirosis  Hypertension  Amoebiasis/Amebiasis (Amoebic Dysentery)  Colon Cancer (Colorectal Cancer)  Postpartum Hemorrhage  Neonatal Sepsis (Sepsis Neonatorum)  Diabetes Mellitus Type 1  Diabetes Mellitus Type 2  Kyphosis

Impaired physical mobility of the lower extremity r/t external fixator @ L leg

Assessment

Nursing Diagnosis

Planning

Nursing Intervention Independent Assisted with normal range of motion exercises and function of lower extremity. Encouraged progressive activities according to level of fatigue.

Rationale

Evaluation

Subjective Impaired Medyo di pa physical ako mobility of the makakilos ng lower extremity gaya r/t dati dahil sa external fixator nakakabit @L sa akini as leg. verbalized Objective c external fixator @ L leg ambulatory

Short Term Goal After 3 days of nursing intervention, he demonstrates and verbalizes proper exercises of the lower extremities & can perform activities of daily living with minimal assistance.

Necessary to regain normal mobility of leg to speed recovery.

Increase patient s use of affected leg.

After 3 days of nursing intervention, goal is met through the regaining of the patient s previous range of motion in the leg & demonstrates proper exercises for the lower extremities. He also does ADL without discomfort.

Impaired physical mobility of the lower extremity r/t external fixator @ L leg

Assessment

Nursing Diagnosis Impaired skin integrity r/t surgical incision.

Planning

Nursing Intervention Independent Vital signs monitored and recorded.

Rationale

Evaluation

Subjective Nagkapasapasa ako na maliliit, wala na ngayon may mga bakas na lan konte, as verbalized. Objective c external fixator @ L leg ambulatory

Short Term Goal After 30 minutes of nursing intervention, proper skin hygiene is demonstrated.

Changes in vitals signs may indicate infection. Cleaning the fixator will minimize the risk for infection.

Taught proper cleaning and checking of the integrity of the fixator. Advised to elevate affected lower extremity from time to time.

After 30 minutes of nursing intervention, the goal is met through demonstration of proper skin hygiene and cleaning care done on the fixator.

This controls swelling and pain.

Breastfeeding Ineffective
Assessment Nursing Diagnosis Breastfeeding, ineffective r/t unsatisfactory feeding process Planning Nursing Intervention Rationale Evaluation

Subjective: Palaging gutom ang baby ko kaya iyak ng iyak as verbalized by the patient Objective: >the baby doesn t respond to other comfort measures given by the mother

(STG) After 8 hours of Nursing Intervention, the baby will be able to stop crying ad will show satisfactory response to breastfeeding process (LTG) After a couple of months of Nursing Intervention, the baby will gain weight and will receive adequate amount of milk supply.

(Independent) The mother >Explain the >to promote understands benefits breast feeding the of breast because breast importance and feeding, the milk contains benefits of mechanisms all breastfeeding involve the necessary and in lactation, the nutrients a demonstrates proper breast baby proper breast care needs for the feeding and most first technique. especially 6 months of life (The goal was the proper completely breastfeeding met) position. >Assist the breastfeeding process as needed > Increase fluid intake >to promote bonding between mother and child >Breastfeeding delays ovulation and therefore the possibility of

another pregnancy >Discuss the importance of adequate nutrition during lactation >Breastfeeding helps stop bleeding after delivery

Ineffective airway clearance r/t lung impairment

Assessment Nursing Diagnosis Ineffective airway clearance r/t lung impairment Planning Nursing Intervention Independent Maintained an open airway. Rationale Evaluation

Subjective Nahihirapan siya na huminga pagkatapos nung aksidente na nangyari as verbalized by sister. Objective use of accessory muscles during inhalation & expiration restlessness c chest tube intact & draining to dark red exudates

Short Term Goal After 10 minutes of nursing intervention, patent airway is achieved & there is improvement in the airway clearance.

Provides for adequate ventilation and gas exchange Endotracheal secretions are present in excessive amounts in postthoracotomy patients due to trauma to the tracheobronchial tree during surgery, diminished lung ventilation and cough reflex.

Performed endotracheal suctioning until she can raise secretions effectively.

After 10 minutes of nursing intervention, goal is met through the patency of airway, demonstration of effective exercises when coughing & lungs are clear on auscultation.

draining output is moderate in amount V/S as follows: T= C P= bpm R= cpm BP= / mmHg

Pain was assessed. Encouraged deep breathing and coughing exercise. Amount, viscosity, color and odor of sputum were monitored.

Helps to achieve maximal lung inflation and to open closed airways. Changes in sputum suggests presence of infection or change in pulmonary status. Opacisication or coloration of sputum may indicate dehydration or infection otherwise. Chest physiotherapy uses gravity to help remove secretions

Performed postural drainage, percussion and vibration as

prescribed. Determined changes in breath sounds through auscultation. Dependent Administered humidification & nebulizer therapy as prescribed.

from the lungs. Indications for tracheal suctioning are determined by chest auscultation. Secretions must be moistened and thinned if they are to be raised from the chest with the least amount of effort.

Ineffective airway clearance r/t lung impairment

Assessment Nursing Diagnosis Impaired physical mobility of the upper extremities r/t thoracotomy Planning Nursing Intervention Independent Patient was assisted with normal range of motion and function of shoulder and trunk. Proper breathing exercises to mobilize thorax were advised. Encouraged progressive activities according to level of fatigue. Rationale Evaluation

Subjective Hindi siya gaano makakilos gawa nung mga nakalagay sa kanya, as verbalized by sister. Objective c chest tube drainage on L lateral abdomen restlessness

Short Term Goal After 3 days of nursing intervention, she demonstrates and verbalizes proper exercises of the upper extremities & can perform activities of daily living gradually.

Necessary to regain normal mobility of arm and shoulder to speed recovery.

Increase patient s use of affected shoulder and arm.

After 3 days of nursing intervention, goal is met through the regaining of the patient s previous range of motion in the shoulders and arms & demonstrates proper exercises for the upper extremities. She also does ADL without discomfort.

Impaired skin integrity r/t traction application

Assessment Nursing Diagnosis Impaired skin integrity r/t traction application Planning Nursing Intervention Independent Vital signs monitored and recorded. Rationale Evaluation

Subjective Nakuha nia ang sugat nya sa paa gawa nun nakabalot sa kanya sa traction, as verbalized by the mother. Objective c Buck s traction @ L leg to 5 lbs weight c slightly dry bed sore & swelling @ L posterior foot

Short Term Goal After 4 days of nursing intervention, proper skin care will be demonstrated by the mother.

Changes in vitals signs may indicate infection. Cleaning the wound will minimize the risk for infection and further swelling. This controls swelling and pain. It also promotes venous return.

Demonstrated proper wound care.

After 4 days of nursing intervention, the goal is met through demonstration of proper skin hygiene and care.

Advised the mother to elevate affected lower extremity from time to time

Impaired skin integrity r/t traction application

Assessment Nursing Diagnosis Altered tissue perfusion r/t decreased Hgb concentration in blood, 122g/L Planning Nursing Intervention Independent Vital signs monitored and recorded. Rationale Evaluation

Subjective Medyo maputla sya simula nun pinasok sya dito, as verbalized by the mother. Objective c Buck s traction @ L leg to 5 lbs weight c slightly dry bed sore & swelling @ L posterior foot c pale lips & conjuctiva Hgb level = 122g/L

Short Term Goal After 8 hours of nursing intervention, tissue perfusion will normalize & maintained.

Changes in vitals signs may indicate complication. These characteristics of pulses, skin color, capillary refill time and temperature indicates impairment in blood circulation.

Assessed circulation of the foot or hand. Checked for the peripheral pulses, color, capillary refill and temperature of fingers or toes.

After 8 hours of nursing intervention, the goal is met through observation of pinkish lips & conjunctiva; and absence of other signs of circulatory impairment.

Assessed for indicators of DVT, including calf tenderness, swelling and positive Homan s sign.

Deep Vein Thrombosis is another complication of circulatory impairment which also may be present on patients with Buck s traction. This will promote venous return and better circulation.

Encouraged to perform foot exercises every hour when awake. Advised to eat foods rich in iron such as organ meats, legumes & green leafy vegetables.

Iron is a carrier of oxygen needed for cellular respiration.

Family Nursing Care Plan

Assessment Nursing Diagnosis Knowledge deficient r/t lack of information resource Planning Nursing Intervention (Independent) >Explain the importance of family planning >Discuss the methods available in the market >Discuss the advantages and disadvantages of each method >refer to health center for DOH programs and free consultations regarding family planning and contraception Rationale Evaluation

Subjective: Hindi po kami ngpaplano ng pamilya as verbalized by the patient Objective: >G5P5 >Low selfesteem

(STG)
After 8 hours of Nursing Intervention, the patient will gain enough knowledge regarding family planning methods

>to regulate the intervals between pregnancies >to select the best family planning method appropriate to them >to improve health and economic status

(LTG)
After a couple of months of Nursing Intervention, the patient will avoid unwanted pregnancies through contraception and will be able to improve their health and economic status

The mother understands the importance and benefits of family planning and shows better understanding of the variety of methods available that will fit their lifestyle. (The goal was partially met)

Impaired Urinary Elimination r/t oral fluid/solid restriction & sensory motor impairment
Assessment Nursing Diagnosis Impaired Urinary Elimination r/t oral fluid/solid restriction & sensory motor impairment Planning Nursing Intervention Independent Assessed patency of foley catheter. Rationale Evaluation

Objective c IVF of D5LR 1L @ 30 gtts/min pale in appearance weak looking on NPO c abdominal dressing, dry & intact (+) anesthetic effect on pelvic & lower extremities c foley catheter draining to yellowish urine, > 30 mL/hr

Short Term Goal After 4 hours of nursing intervention, normal urine elimination and output will be maintained.

Provides basis for further assessment & action. Prevents or reduces risk of contamination of foley catheter.

Used asepsis and hand hygiene in providing care and manipulating the urinary drainage system. Assessed color, volume, odor and components of

After 4 hours of nursing intervention, the goal is met through exhibition of adequate urinary output and patent drainage system.

Provides information about adequacy of urine

urine.

output, condition and patency of foley catheter and debris in urine.

Dependent Administered IV fluids such as PNSS on fast drip as prescribed.

By regulating the amount of sodium, the kidney can regulate the volume of body fluids.

Ineffective tissue perfusion related to vasoconstriction of blood vessels

Assessment Nursing Diagnosis > Ineffective tissue perfusion related to vasoconstriction of blood vessels. Planning Nursing Intervention > Monitored blood pressure every 4hours. > Instructed to have enough rest on semi fowlers position. Rationale Evaluation

(Subjective) > Nahihilo ako as Verbalized (Objective) _ PR = 85 bpm _ RR = 30 bpm _160/100mmHg

After 4 hours of nursing intervention the pt blood pressure will decrease from 160/ 100mmHg to 120/80mmHg.

> To know the base line of BP

> Sodium tends to be excreted at a faster rate.

> After 4 hours of nursing intervention the patient s blood pressure was decreased from 160/100mmHg to 140/90mmHg.

> Instructed to > To reduce eat edema that may low fat and low activate renin salt angiotensinaldosterone diet. system. > Administered antihypertensive drug as ordered. > To control the BP and to avoid other complications.

Diarrhea
Assessment Nursing Diagnosis Diarrhea related to presence of toxins. Planning Nursing Intervention Independent: Observe and record stool frequency, characteristics, amount and precipitating factors. Promote bed rest. Rationale Evaluation

Subjective: Madalas akong dumumi ngayon kaysa kahapon as verbalized by patient. Objective: Increased peristalsis. Frequent watery stools. Abdominal pain. V/S taken as follows: T: 36.6 P: 80 R: 18 Bp: 110/90

After 4 hours of nursing interventions, the patient will report reduction in frequency of stools.

Helps differentiate individual disease and assesses severity of episode. Rest decreases intestinal motility and reduces metabolic rate. Urge to defecate may occur without warning and uncontrollable, increasing risk of incontinence or falls if

After 4 hours of nursing intervention s, the patient was able to report reduction in frequency of stools.

Provide bedside

facilities are not close at hand. Identify foods and fluids that precipitate diarrhea. Restart oral fluid intake gradually. Offer clear liquids hourly, and avoid cold fluids. Avoiding intestinal irritants promotes intestinal rest. Provides colon rest by omitting or decreasing stimulus of foods or fluids. Gradual consumption of liquids may prevent cramping and recurrence of diarrhea. Cold fluids can increase intestinal motility.

Encourage to eat foods like banana and apple. Avoid foods that are oily, spicy and caffeine.

Fruits that are stool former.

Foods that may precipitate gastric cramping.

Collaborative: Administer Decreases G.I antidiarrheals motility or as peristalsis and prescribed by diminishes the digestive physician. secretions to relieve cramping and diarrhea.

Chronic Obstructive Pulmonary Disease (COPD)

Assessment Nursing Diagnosis Ineffective airway clearance related to increased production of secretions. Planning Nursing Intervention Independent: Assist patient to assume position of comfort, e.g., elevate head of bed, encourage patient to lean on overbed table or sit on the edge of the bed. Keep environmental pollution to a minimum, e.g., dust, smoke and feather pillows, according to individual situation Rationale Evaluation

Subjective: Nahihirapan ako huminga as verbalized by the patient. Objective: Use of accessory muscle. Dyspnea Productive cough V/S taken as follows: T: 36.7 P: 57 R: 25 Bp: 100/80

After 4 hrs. Of nursing interventions, the client will demonstrate behaviors to improve airway clearance. e.g. cough effectively and expectorate secretions.

Elevation of the head of the bed facilitates respiratory function by use of gravity.

Precipitators of allergic type or respiratory reactions that can trigger or exacerbate onset of acute episode.

After 4 hrs. Of nursing intervention s, the client was able to demonstrate behaviors to improve airway clearance. e.g. cough effectively and expectorate secretions.

 Encourage or assist with pursed lip breathing exercises.

Provides patient with some means to cope or control dyspnea and reduce air trapping. Coughing is most effective in an upright position or head down position after chest percussion.

Observe characteristics of cough like persistent or hacking or moist. Assist with measures to improve effectiveness o cough effort. Dependent: Administer medication as prescribed by the physician.

A variety of medications may be used to decrease mucus and to improve respiration.

 Provide supplemental humidification like nebulizer

Humidity helps reduce viscosity of secretions, facilitating expectoration, and may reduce or prevent formation of thick mucus plugs in bronchioles.

Fever
Assessment Nursing Diagnosis Hyperthermia related to dehydration. Planning Nursing Intervention Independent: Monitor heart rate and rhythm. Rationale Evaluation

Subjective: Mainit ang pakiramdam ko as verbalized by the patient. Objective: Flushed skin, warm to touch. Restlessness . V/S taken as follows: T: 38.1 P: 70 R: 19 BP: 110/90

After 4 hrs. Of nursing interventions, the patient will maintain core temperature within normal range.

Dysrhythmias and ECG changes are common due to electrolyte imbalance and dehydration and direct effect of hyperthermia on blood and cardiac tissues. To monitor or potentiates fluid and electrolyte loses. To decrease Temperature

After 4 hrs. Of nursing intervention s, the patient was able maintain core temperature within normal range.

Record all sources of fluid loss such as urine, vomiting and diarrhea.

Promote surface cooling

by means of tepid sponge bath.

by means through evaporation and conduction. To minimize shivering.

Wrap extremities with cotton blankets. Provide supplemental oxygen.

To offset increased oxygen demands and consumption. To support circulating volume and tissue perfusion. To reduce metabolic demands and oxygen consumption

Administer replacement fluids and electrolytes.

Maintain bed rest.

Provide high calorie diet, tube feedings, or parenteral nutrition. Administer antipyretics orally or rectally as prescribed by the physician.

To increased metabolic demands.

To facilitate fast recovery.

TB Meningitis
Assessment Nursing Diagnosis Risk for ineffective cerebral tissue perfusion related cerebral edema Planning Nursing Intervention Independent: Maintain head or neck in midline or neutral position, support with small towel rolls and pillows. Rationale Evaluation

Subjective: Masakit ang ulo ko. as verbalized by the client. Objective: Restlessness. Changes in motor or sensory responses. V/S taken as follows: T: 37.7 P: 50 R: 12 Bp: 130/90

After 4 hrs. Of nursing interventions, the client will demonstrate stable vital signs and absence of signs of intracranial pressure.

Turning head to one side compresses the jugular veins and inhibits cerebral venous drainage, thereby increasing intracranial pressure. Continual activity can increase intracranial pressure.

After 4 hrs. Of nursing intervention s, the client was able to demonstrate stable vital signs and absence of signs of intracranial pressure.

Provide rest periods between care activities and limit duration of procedures.

 Decrease extraneous stimuli and provide comfort measures like back massage, quiet environment, soft voice. Help patient avoid or limit coughing, vomiting, straining at stool, bearing down as possible. Observe for seizure activity and protect patient from injury.

Provides calming effect, reduces adverse physiological response and promotes rest to maintain or lower intracranial pressure. These activities increase thoracic and intra-abdominal pressure which can increase intracranial pressure.

Seizure can occur as result of cerebral irritation, hypoxia or increase intracranial pressure.

Collaborative: Restrict fluid intake as indicated. Fluid restriction may be needed to reduce cerebral edema. Reduces hypoxemia.

Administer supplemental oxygen as indicated.

Pedia TB Meningitis
Assessment Nursing Diagnosis Hyperthermia related to infectious process and dehydration. Planning Nursing Intervention Independent: Monitor heart rate and rhythm. Rationale Evaluation

Subjective: Nilalagnat ang anak ko as verbalized by the mother. Objective: Flushed skin, warm to touch. Increased respiratory rate. V/S taken as follows: T: 37.8 P: 110 R: 45

After 4 hrs. Of nursing interventions , the client will maintain core temperature within normal range

Dysrhythmias and ECG changes are common due to electrolyte imbalance and dehydration and direct effect of hyperthermia on blood and cardiac tissues. To monitor or potentiates fluid and electrolyte loses.

After 4 hrs. Of nursing intervention s, the client was able maintain core temperature within normal range.

Record all sources of fluid loss such as urine, vomiting and diarrhea.

Promote To decrease surface temperature by cooling by means through means evaporation of tepid sponge and

bath. Wrap extremities with cotton blankets. Provide supplemental oxygen.

conduction. To minimize shivering.

To offset increased oxygen demands and consumption. To support circulating volume and tissue perfusion. To reduce metabolic demands and oxygen consumption. To increased metabolic demands.

Administer replacement fluids and electrolytes.

Maintain bed rest.

Provide high calorie diet, tube feedings, or parenteral

nutrition.

Administer antipyretics orally or rectally as prescribed by the physician.

To facilitate fast recovery.

Ineffective Airway Clearance r/t secretions in the bronchi

Assessment Nursing Diagnosis Planning Nursing Intervention Independent Vital signs monitored and recorded. Assisted in semifowler s position. Rationale Evaluation

Subjective Ineffective Nahihirapan Airway akong huminga Clearance dahil sa r/t secretions in kakaubo the bronchi ko, as verbalized. Objective pale in appearance dyspnea (+) use of accessory muscles when breathing (+) productive cough RR=24cpm

Short Term Goal After 4 hours of nursing intervention, airway patency will be maintained, secretions will be readily expectorated and there will be signs of reduction in congestion.

This is for baseline comparison. Proper positioning helps in draining secretions. This will promote proper lung expansion.

Encouraged deep breathing exercise. Dependent Administered prescribed medications.

After 4 hours of nursing intervention, the goal is met through maintenance of airway patency and reduction in congestion.

Prescribed meds such as bronchodilators helps in aiding effective airway

clearance.

Provided Supplemental humidification via use of nebulizer.

Nebulization helps in liquefying secretions for better and faster expectorating the secretions.

Cholecystectomy
Assessment Nursing Diagnosis Impaired tissue integrity related to presence of secretions Planning Nursing Intervention Independent: Change dressings as often as needed and use karaya powder around the incision. Rationale Evaluation

Subjective: Masakit ang opera ko as verbalized by the patient. Objective: Facial mask of pain. Limited range of motion. Disruption of skin. V/S taken as follows: T: 37.2 P: 90 R: 19 BP: 110/80

After 3 days of nursing interventions, the patient will achieve timely wound healing without complications.

Keeps the skin around the incision clean and provides a barrier to protect skin from excoriation. Ostomy appliance may be used to collect heavy drainage for accurate measurement of output and protection of the skin.

After 3 days of nursing interventions, the patient was able to achieve timely wound healing without complications.

Use disposable ostomy bag over a stab wound drain.

 Place patient in low or semifowlers position. Observe for skin, sclerae, urine for change of color. Note color and consistency of stools.

To facilitates drainage of bile.

Developing jaundice may indicate obstruction of the bile flow.

Clay colored stools result when bile is not present in the intestine. Signs suggestive of abcess of fistula formation, requiring medical ntervention.

Investigate reports of increased right upper quadrant pain, development of fever, tachycardia.

Collaborative: Administer antibiotics as prescribed. Monitor laboratory studies like white blood cells.

Necessary for treatment of abscess or infection. Leukocytosis reflects inflammatory process.

Hyperbilirubinemia (Jaundice)
Assessment Nursing Diagnosis Risk for injury related to prematurity Planning Nursing Intervention Independent: Note the infant s age. Rationale Evaluation

Subjective: Naninilaw ang mata at balat ng baby ko as verbalized by the mother. Objective: Skin appearing light to bright yellow. Sclerae appearing yellow. Dark amber urine. V/S taken as follows: T: 36.3 P: 110 R: 30

After 7 days of nursing interventio ns, the patient skin color will be norma.

May aids in diagnosing underlying cause in connection with the appearance of jaundice. To allow for utilization of alternate pathways for bilirubin excretion To expose the entire skin in phototherapy.

After 7 days of nursing intervention s, the patient skin color was normal.

Assist with phototherapy treatment.

Have the infant completely undressed. Keep the eyes and gonads covered.

To protect them from the

constant exposure to high intensity light. Develop a systematic schedule of turning the infant. Ideally every 2 hours so that all the surfaces are exposed.

Collaborative: Obtain To have a bilirubin baseline data if level as the therapeutic directed. regimen is effective. Administer fluids as directed. To ensure adequate hydration.

Caesarean Delivery
Assessment Nursing Diagnosis Acute pain related to disruption of skin, tissue, and muscle integrity. Planning Nursing Intervention Independent: Evaluate pain regularly noting characteristics, location, intensity (0-10 scale). Identify specific activity limitations. Recommend planned or progressive exercise. Rationale Evaluation

Subjective: Masaki yung tahi ko as verbalized by patient. Objective: Facial mask of pain. Guarding behavior. Narrowed focus. V/S taken as follows: T: 37.3 P: 80 R: 18 Bp: 110/90

After 8 hours of nursing interventions , the patient pain will be relieved or controlled.

Provides information about need for or effectiveness of interventions. Prevents undue strain on operative site. Promotes return of normal function and enhances feelings of general well being. Prevents fatigue and conserves

After 8 hours of nursing intervention s, the patient pain was relieved or controlled

Schedule adequate rest periods.

energy for healing. Review importance of nutritious diets and adequate fluid intake. Provides elements necessary for tissue regeneration or healing. May relieve pain and enhance circulation. Improves circulation, reduces muscle tension and anxiety associated with pain. Relieves muscle and emotional tension.

Reposition as indicated.

Provide additional comfort measures like back rub.

Encourage use of relaxation technique like deep breathing exercises.

Collaborative: Administer analgesics or non steroidal antiinflammatory drugs as prescribed. To relieve mild or moderate pain.

Pott s Disease
Assessment Nursing Diagnosis Acute pain related to inflammatory process. Planning Nursing Intervention Independent: Investigate report of pain, noting characteristics, location, intensity (0-10 scale). Provide firm mattress and small pillows. Rationale Evaluation

Subjective: Sumasakit ang likod ko as verbalized by patient. Objective: Facial mask of pain. Self narrowed focus. Fatigue. V/S taken as follows: T: 37.3 P: 80 R: 18 Bp: 120/90

After 8 hours of nursing interventions , the patient will be able to incorporate relaxation skills and diversional activities into pain control program.

Helpful in determining pain management needs and effectiveness of the program. Soft or sagging mattress and large pillows inhibits the proper body alignment. In acute phase, total bed rest may be necessary to limit pain.

After 8 hours of nursing intervention s, the patient will be able to incorporate relaxation skills and diversional activities into pain control program.

Suggest patient assume position of proper comfort while in bed or chair. Promote bed rest as

indicated.

Encourage frequent changes of position.

Prevents general fatigue

and joint stiffness.

Apply warm or moist compress on the affected area several times a day.

Heat promotes muscle relaxation and mobility, decreases pain and relieves morning stiffness. Promotes relaxation and reduces muscle tension

Provide gentle massage.

Encourage use of Stress management techniques.

Promotes relaxation, provides sense of control and may enhance coping activities.

Collaborative: Administer non steroidal antiinflammatory drugs as prescribed.

These drugs control mild to moderate pain and inflammation by inhibition of prostaglandin synthesis. To prevent further infection..

Administer antibiotic as prescribed.

Endometrial Cancer
Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective: Natatakot ako sa karamdaman ko as verbalized by patient. Objective: Increased tension. Restlessness. Hopelessness. V/S taken as follows: T: 37.2 P: 92 R: 20 Bp: 110/90

Fear related to situational crisis.

After 4 hours of nursing interventions , the patient will display appropriate range of feelings and lessened fear.

Independent: Review patient s previous experience with cancer.

Clarifies patient s perceptions and assist in identification of fears and misconceptions based on diagnosis and experience with cancer. Provides opportunity to examine realistic fears and misconceptions about diagnosis. Provides assurance that patient is not

yAfter 4 hours of nursing intervention s, the patient was able to display appropriate range of feelings and lessened fear.

Encourage patient to share thoughts and feelings.

Maintain frequent contact with

patient. Talk with and touch patient

alone or rejected and fostering trust.

as appropriate. Provide accurate, consistent information regarding diagnosis and prognosis. Explain procedures, providing opportunity for questions and honest answers. Can reduce anxiety and enable patient to make decision and choices based on realities. Accurate information allows patient to deal more effectively with the situation, thereby reducing anxiety and fear. Facilitates rest, conserves energy, and may enhance

Promote calm, quiet environment.

coping abilities. Collaborative:

Refer for additional resources for counseling or support as needed.

Maybe useful from time to time to assist patient in dealing with anxiety.

Cholelithiasis

Assessment

Nursing Diagnosis
yAcute pain related to inflammation and distortion of tissues.

Planning

Nursing Intervention
Independent: yObserve and document location of pain, severity (0-10 scale), and character of pain. yPromote bed rest, and in low fowlers position. yUse soft cotton linens, calamine lotion, oil bath and cool or moist compress as indicated. yControl environmental temperature. yEncourage use of relaxation technique.

Rationale

Evaluation

Subjective: Masakit ang tagiliran ko as verbalized by patient. Objective: yFacial mask of pain. yGuarding behavior. ySelf foucusing. yV/S taken as follows: T: 37.3 P: 80 R: 18 Bp: 110/90

yAfter 8 hours of nursing interventions , the patient pain will be relieved or controlled.

yAssist in differentiating cause of pain and provides information about disease progression, development of complications and effectiveness of intervention. yBed rest in low fowlers position reduces intra abdominal pressure. yReduces irritation, dryness of the skin and itching sensation. yCool surroundings aid in minimizing dermal discomfort. yPromotes rest, redirects attention, may enhance coping.

yAfter 8 hours of nursing intervention s, the patient pain was relieved or controlled.

Collaborative: Administer medication as prescribed: yAnticholinergics. yNarcotics

yRelieves reflex spasm or smooth muscle contraction and assist with pain management. yGiven to reduce severe pain.

Typhoid Fever

Assessment

Nursing Diagnosis
yHyperthermia related to increased metabolic rate, illness.

Planning

Nursing Intervention
Independent: yMonitor patient temperature degree and patterns. yObserve for shaking chills and profuse diaphoresis. yWash hands with anti-bacterial soap before and after each care of activity and encourage proper hygiene. yProvide tepid sponge baths and avoid the use of ice water and alcohol. yMonitor for signs of deterioration of condition or failure to improve with therapy. Collaborative: yAdminister antipyretics as prescribed.

Rationale

Evaluation

Subjective: Mainit ang pakiramdam ko as verbalized by patient. Objective: yFlushed skin, warmed to touch. yRestlessness. yV/S taken as follows: T: 38.9 P: 80 R: 21 Bp: 100/80

yAfter 7 days of nursing interventions , the patient will demonstrate temperature within normal range and free from chills.

yFever pattern may aids in diagnosing underlying disease. yChills often precede during high temperature and in presence of generalized infection. yReduces cross contamination and prevents the spread of infection. yMay help reduce fever. Use of ice water and alcohol may cause chills and can elevate temperature. yMay reflect inappropriate antibiotic therapy.  yUsed to reduce fever by its

yAfter 7 days of nursing intervention s, the patient was able to demonstrate temperature within normal range and free from chills.

yAdminister antibiotics as prescribed.

central action on the hypothalamus. yTo control the spread of infection.

Cholecystectomy (Gallbladder Removal)

Assessment

Nursing Diagnosis
yKnowledge deficient regarding condition and self care related to information misinterpre tation.

Planning

Nursing Intervention
Independent: yReview disease process, surgical procedure or prognosis. yDemonstrate care of incisions or dressing or drains. yEmphasize importance of maintaining low fat diet, eating small frequent meals, gradual reintroduction of foods or fluids containing fats over 4 to 6 month period. yDiscuss avoiding or limiting use of alcoholic beverages. yInform patient that loose stools may occur for several months. yIdentify signs and symptoms

Rationale

Evaluation

Subjective: Hindi ko alam ang gagawin sa sugat ko as verbalized by the patient. Objective: yStatement of misinterpretati on. yRequest for information. yV/S taken as follows: T: 37.3 P: 80 R: 19 BP: 120/80

yAfter 8 hours of nursing interventions the patient will verbalize understanding of therapeutic needs.

yProvides knowledge base on which patient can make informed choices. yPromotes independence in care and reduces risk of complications. yDuring initial 6 months after surgery, low fat diet limits need for bile and reduces discomfort associated with inadequate digestion of fats. yMinimizes the risk of pancreatic involvement. yIntestines require time to adjust to stimulus of continuous output of bile. yIndicators of

yAfter 8 hours of nursing intervention s the patient was able verbalize understandi ng of therapeutic needs.

requiring notification of healthcare provider like dark urine, jaundiced color of eyes or skin, clay colored stools. yReview activity limitations depending on individual situation.

obstruction of bile flow or altered digestion, requiring further evaluation and intervention. yResumption of usual activities is normally accomplished within 4-5 weeks.

Urinary Tract Infection (UTI)

Assessment

Nursing Diagnosis
Acute pain related to urinary tract infection.

Planning

Nursing Intervention
Independent: yAssess pain, noting location, intensity (scale of 0 10), duration. yEncourage increased fluid intake. yInvestigate report of bladder fullness. yObserve for changes in mental status, behavior or level of consciousness. yProvide comfort measure like back rub, helping patient assume position of comfort. Suggest use of relaxation technique and deep breathing exercises. yEncourage use of sitz baths, warm soaks to the perineum. Collaborative:

Rationale

Evaluation

Subjective: Masakit ang pagihi ko as verbalized by the patient. Objective: yFacial grimace. yRestlessness. yV/S taken as follows: T: 37.3 P: 82 R: 19 BP: 120/90

yAfter 7 days of nursing intervention s, the patient pain will be relieved or controlled.

yProvides information to aid in determining choice or effectiveness of interventions. yIncreased hydration flushes bacteria and toxins. yUrinary retention may develop, causing tissue distention ( bladder or kidney), and potentiates risk for further infection. yAccumulation of uremic waste and electrolyte imbalances may be toxic to the CNS. yPromotes relaxation, refocuses attention, and may enhance

yAfter 7 days of nursing intervention s, the patient pain will be relieved or controlled.

yAdminister antibacterial as prescribed.

coping abilities. yPromotes muscle relaxation. yReduces bacteria present in urinary tract and those introduced by drainage system

CEREBROVASCULAR ACCIDENT (CVA)

Assessment

Nursing Diagnosis
Impaired verbal communication related to loss of facial or oral muscle tone control.

Planning

Nursing Intervention
yProvide alternative methods of communication, like pictures or visual cues, gestures or demonstration. yAnticipate and provide for patient s needs. yTalk directly to patient. Speaking slowly and directly. Use yes or no question to begin with. ySpeak in normal tones and avoid talking too fast. Give patient ample time to respond. yEncourage family members and visitors to persist efforts to communicate with the patient.

Rationale

Evaluation

SUBJECTIVE: Nahihirapan ako magsalita , as verbalized by the client. OBJECTIVE: BP: 150/100 PR: 74 RR: 30 T: 36.4 As manifested by: yDifficulty producing speech. yFacial paralysis. yMuscle and facial tension.

After 1 hr. of nursing intervention, the patient will establish method of communication in which needs can be expressed.

yProvide communication needs or desires based on individual situation or underlying deficit. yHelpful in decreasing frustration when dependent on others and unable to communicate desires. yIt reduces confusion or anxiety and having to process and respond to large amount of information at one time. yPatient is not necessary hearing impaired and raising voice may irritate or anger the patient. yIt is important for

After 1 hr. of nursing intervention, the patient was able to establish method of communication in which needs can be expressed.

family members to continue talking to the patient to reduce patients isolation, promote establishment of effective communication and maintain sense of connectedness or bonding with the family.

Neonatal Pneumonia
Assessment Nursing Diagnosis
Impaired gas exchange r/t collection of secretions affecting oxygen exchange across alveolar membrane.

Planning

Nursing Intervention
Independent: yAssess respiratory rate, depth and ease. yMonitor body temperature. yElevate head of the bed and change position frequently. yLimit visitors as indicated. yInstitute isolation precaution. ySuction as indicated. yAssist with nebulizer treatments. yMonitor effectiveness of antimicrobial therapy. Collaborative: yAdminister antimicrobials as prescribed.

Rationale

Evaluation

Subjective: Nahihirapan huminga ang baby ko dahil sa ubo as verbalized by the mother. Objective: yDyspnea yTachycardia yV/S taken as follows: T: 37.7 P: 125 R: 50

yAfter 4 hours of nursing interventions, the patient will achieve timely resolution of current infection without complications.

yManifestation of respiratory distress is dependent on indicative of the degree of lung involvement and underlying general status. yHigh fever greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation. yPromotes expectoration, clearing or infection. yReduces likelihood of exposure to other

yAfter 4 hours of nursing intervention s, the patient will achieve timely resolution of current infection without complicatio ns.

infectious pathogens. yIsolation technique may be desired to prevent spread and protect patient from other infectious process. yStimulates cough or mechanically clears airway in patient who is unable to cough effectively. yFacilitates liquefaction and removal of secretions. ySigns of improvement in condition should occur within 24- 48 hrs. yThese drugs are used to combat most of the microbial pneumonias.

Community Acquired Pneumonia

Assessment Nursing Diagnosis
Acute pain r/t localized inflammation and persistent cough.

Planning

Nursing Intervention
Independent: yElevate head of the bed, change position frequently. yAssist patient with deep breathing exercises. yDemonstrate or help patient learn to perform activity like splinting chest and effective coughing while in upright position. yForce fluids to at least 3000 ml per day and offer warm, rather than cold fluids.

Rationale

Evaluation

Subjective: Masakit ang dibdib ko as verbalized by patient. Objective: yUse of accessory muscle. yDyspnea yFatigue. yV/S taken as follows: T: 37.3 P: 80 R: 25 Bp: 120/80

yAfter 4 hours of nursing interventions , the patient will display patent airway with breath sounds clearing and absence of dyspnea.

yLowers diaphragm, promoting chest expansion and expectoration of secretions. yDeep breathing facilitates maximum expansion of the lungs and smaller airways. yCoughing is a natural self cleaning mechanism. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort. yFluids especially

yAfter 4 hours of nursing intervention s, the patient was able to display patent airway with breath sounds clearing and absence of dyspnea.

warm liquids aid in mobilization and expectoration of secretions. Collaborative: yAdminister medications as prescribe: mucolytics or expectorants. yProvide supplemental fluids. yAids in reduction of bronchospas m and mobilization of secretions. yFluids are required to replace losses and aid in mobilization of secretions.

Dengue Fever
Assessment Nursing Diagnosis
yInjury, risk for hemorrhage related to altered clotting factor.

Planning

Nursing Intervention
Independent: yAssess for signs and symptoms of G.I bleeding. Check for secretions. Observe color and consistency of stools or vomitus. yObserve for presence of petechiae, ecchymosis, bleeding from one more sites. yMonitor pulse, Blood pressure. yNote changes in mentation and level of consciousness. yAvoid rectal temperature, be gentle with GI tube insertions. yEncourage use of soft toothbrush, avoiding straining

Rationale

Evaluation

Subjective: Bigla na lang dumugo ang ilong ng anak ko as verbalized by the mother. Objective: yWeakness and irritability. yRestlessness. yV/S taken as follows: T: 37.5 P: 55 R: 18 Bp: 90/70

yAfter 1 hr. Of nursing interventions, the client will be able demonstrate behaviors that reduces the risk for bleeding.

yThe G.I tract (esophagus and rectum) is the most usual source of bleeding of its mucosal fragility. ySub-acute disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors. yAn increase in pulse with decreased Blood pressure can indicate loss of circulating blood volume. yChanges may indicate cerebral perfusion secondary to

yAfter 1 hr. Of nursing intervention s, the client will be able demonstrate behaviors that reduces the risk for bleeding.

for stool, and forceful nose blowing. yUse small needles for injections. Apply pressure to venipuncture sites for longer than usual. yRecommend avoidance of aspirin containing products. Collaborative: yMonitor Hb and Hct and clotting factors.

hypovolemia, hypoxemia. yRectal and esophageal vessels are most vulnerable to rupture. yIn the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding. yMinimizes damage to tissues, reducing risk for bleeding and hematoma. yProlongs coagulation, potentiating risk of hemorrhage. yIndicators of anemia, active bleeding, or impending complications.

Nausea & Vomiting

Assessment Nursing Diagnosis
yNutrition imbalanced less than body requirements related to nausea and vomiting.

Planning

Nursing Intervention
Independent: yAuscultate bowel sounds, noting absence or hyperactive sounds. yEliminate smells from the environment. yAvoid foods that might cause or exacerbate abdominal cramping like caffeinated beverages, chocolate, orange juice. yMeasure abdominal girth. yObserve skin or mucous membrane dryness, and turgor. Note peripheral edema and sacral edema. yAssess

Rationale

Evaluation

Subjective: Nagsusuka ako as verbalized by patient. Objective: yHyperactive bowel sounds. yPale conjunctiva and mucus membrane. yV/S taken as follows: T: 36.6 P: 98 R: 18 Bp: 110/90

yAfter 3 days. Of nursing interventions, the client will be able to maintain usual weight.

yInflammation or irritation of the intestine may be accompanied by intestinal hyperactivity, diminished water absorption and diarrhea. yReduces gastric stimulation and vomiting response. yMight increase abdominal cramping. yProvides quantitative evidence of changes in gastric or intestinal distention. yHypovolemia, fluid shifts and nutritional

yAfter 3 days. Of nursing intervention s, the client will be able to maintain usual weight.

abdomen frequently for return to softness, appearance of normal bowel sounds, and passage of flatus. yWeigh daily. Collaborative: yMonitor BUN, protein, prealbumin or albumin, glucose, nitrogen balance as indicated. yAdvance diet as tolerated.

deficits contribute to poor skin turgor, edematous tissue. yIndicates return of normal bowel function and ability to resume oral intake. yInitial losses or gains reflect changes in hydration. yReflects organ function and nutritional status and needs. yCareful progression of diet when intake is resumed reduces risk of gastric irritation.

Appendicitis

Assessment

Nursing Diagnosis
Acute pain related to inflammation of tissues.

Planning

Nursing Intervention
Independent: yInvestigate pain reports, noting location, duration, intensity (0-10 scale), and characteristics (dull, sharp, constant). yMaintain semifowlers position. yMove patient slowly and deliberately. yProvide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises. Provide diversional activities. yProvide frequent oral care. Remove noxious environmental stimuli. Collaborative:

Rationale

Evaluation

Subjective: Masakit ang tiyan ko as verbalized by patient. Objective: yFacial mask of pain. yGuarding behavior. yRebound tenderness. yV/S taken as follows: T: 37.3 P: 80 R: 18 Bp: 110/90

yAfter 4 hours of nursing interventions , the patient will demonstrate use of relaxation skills, other methods to promote comfort.

yChanges in location or intensity are not uncommon but may reflect developing complications. yReduces abdominal distention, thereby reduces tension. yReduces muscle tension or guarding, which may help minimize pain of movement. yPromotes relaxation and may enhance patients coping abilities by refocusing attention. yReduces nausea and vomiting, which can increase intra-abdominal pressure or pain. yReduce

yAfter 4 hours of nursing intervention s, the patient was able to demonstrate use of relaxation skills, other methods to promote comfort.

yAdminister analgesics as prescribed.

metabolic rate and aids in pain relief and promotes healing.

Abruptio Placenta

Assessment

Nursing Diagnosis
Acute pain related to collection of blood between uterine wall and placenta.

Planning

Nursing Intervention
Independent: yMonitor amount of bleeding by weighing all pads. yInvestigate pain reports, noting location, duration, intensity (0-10 scale), and characteristics (dull, sharp, constant). yMonitor maternal vital signs and fetal heart rate through continuous monitoring. yMeasure and record fundal height. yPosition mother in the left lateral position, with the head of the bed elevated. yProvide comfort measure like back rubs, deep breathing.

Rationale

Evaluation

Subjective: Bigla na lang sumakit ng matindi ang tiyan ko , kahit 22 linggo palang ang ipinagbubuntis ko (Im 22 weeks
pregnant and I feel a sharp pain in my abdomen) as

After 8 hours of nursing interventions, the patient will demonstrate use of relaxation skills, other methods to promote comfort

verbalized by the patient. Objective: yAbdominal guarding. yMuscle tension. yIrritability. yV/S taken as follows: T: 37.3 P: 95 R: 22 Bp: 100/70

yTo measure the amount of blood loss. yChanges in location or intensity are not uncommon but may reflect developing complications. yEarly recognition of possible adverse effects allows for prompt intervention. yFundal height may increase with concealed bleeding. yTo enhance placental perfusion. yPromotes relaxation and may enhance patients coping abilities by

After 8 hours of nursing interventions, the patient was able to demonstrate use of relaxation skills, other methods to promote comfort.

Instruct in relaxation or visualization exercises. Provide diversional activities. Collaborative: yAdminister oxygen as indicated.

refocusing attention.      yTo supply adequate oxygen to the fetus and mother and prevents further complication.

Hyperthyroidism

Assessment

Nursing Diagnosis
Fatigue related to hypermetabolic state with increased energy requirements.

Planning

Nursing Intervention
Independent: yMonitor vital signs, noting pulse rate at rest and when active. yNote development of tachypnea, dyspnea, pallor, and cyanosis. yProvide quiet environment, cool room, decreased sensory stimuli, soothing colors, quiet music. yEncourage patient to restrict activity and rest in bed as much as possible. yProvide comfort measures like judicious touch and cool showers. yAvoid topics that irritate or upset the patient. Discuss ways to respond

Rationale

Evaluation

Subjective: Madali akong mapagod, pakiramdam ko hinag hina ako (I

get tired easily and I feel very weak) as

verbalized by patient. Objective: yDecreased performance. yJittery behavior. yIrritability yV/S taken as follows: T: 37.1 P: 108 R: 22 Bp: 120/80

After 8 hours of nursing interventions, the patient will display improved ability to participate in desired activities.

yPulse is typically elevated and, even at rest, tachycardia (up to 160 beats/min) may be noted. yOxygen demand and consumption are increased in hypermetabolic state, potential risk of hypoxia with activity. yReduces stimuli that may aggravate agitation, hyperactivity and insomnia. yHelp counteract effects of increased metabolism. yMay decrease nervous energy, promoting relaxation. yIncreased

After 8 hours of nursing interventions, the patient was able to display improved ability to participate in desired activities.

to these feelings.

Collaborative: yAdminister medications as indicated like sedatives.

irritability of the CNS may cause patient to be easily excited, agitated, and prone to emotional outburst. yTo combat nervousness, hyperactivity, and insomnia.

Anemia

Assessment

Nursing Diagnosis
jActivity intolerance related to imbalance between oxygen supply (delivery) and demand.

Planning

Nursing Intervention
Independent: jAssess patients ability to perform normal task or activities of daily living. jNote changes in balance/ gait disturbance, muscle weakness. jRecommend quiet atmosphere, bed rest if indicated. jElevate the head of the bed as tolerated. jProvide or recommend assistance with activities or ambulation as necessary, allowing patient to do as much as possible. jPlan activity

Rationale

Evaluation

Subjective: jNanghihina ako,kadalasan hindi ko matapos ang mga gawain ko

(Im feeling weak, I cant even complete my chores) as

verbalized by the patient. Objective: jFatigue. jGreater need for sleep and rest. jV/S taken as follows: T: 36.9 P: 75 R: 18 BP: 100/80

Short term: After 8 hours of nursing interventions the patient will: jReport an increase in activity tolerance including activities of daily living. jDemonstrate a decrease in physiological signs of intolerance. jDisplay laboratory values within acceptable range. Long term: After months of nursing interventions, the patient: jIs free form weakness and risk for complications has been prevented.

jInfluences choice of interventions or needed assistance. jMay indicate neurological changes associated with vitamin B12 deficiency, affecting patient safety or risk of injury. jEnhances rest to lower bodys oxygen requirements, and reduces strain on the heart and lungs. jEnhances lung expansion to maximize oxygenation for cellular uptake. jAlthough help may

jPatient reveals an increase in activity tolerance, demonstrating a reduction in physiological signs of intolerance and laboratory values within normal range.

progression with patient, including activities that the patient views essential. Increase levels of activities as tolerated. jIdentify or implement energy saving technique like sitting while doing a task. Collaborative: jMonitor laboratory studies. Hb or Hct and RBC count, arterial blood gases (ABGs).

be necessary, self esteem is enhanced when patient does some things for self. jPromotes gradual return to normal activity level and improved muscle tone or stamina without undue fatigue. jEncourages patient to do as much as possible, while conserving limited energy and preventing fatigue. jIdentifies deficiencies in RBC components affecting oxygen transport and treatment needs or response to therapy.

Preterm Labor

Assessment

Nursing Diagnosis
Activity intolerance related to muscle or cellular hypersensitivity

Planning

Nursing Intervention
Independent: Assess status of the client and fetus. Encourage bed rest with patient in side lying position. Apply external uterine and fetal monitoring. Monitor patients vital signs closely, every 15 minutes. Instruct patient to report any feelings of difficulty of breathing or chest pain, dizziness, nervousness and irregular heart beats. Monitor uterine contractions, including frequency and domain.

Rationale

Evaluation

Subjective: Bigla na lang humilab ang tiyan ko, parang manganganak na ko (I feel a sudden as verbalized by patient. Objective: Continued uterine contraction. Facial mask of pain. Irritability. V/S taken as follows: T: 37.3 P: 84 R: 19 Bp: 100/80
contraction, I thought I am in labor)

After 8 hours of nursing interventions , the patient will use identified techniques to enhance activity intolerance.

Assessment provides a baseline date for future comparisons. Bed rest relieves pressure of the fetus on the cervix. Uterine and fetal monitoring provides evidence of maternal and fetal well being. Maternal pulse over 120 beats per minute or persistent tachycardia or tachypnea, chest pain, dyspnea and adventitious breath sounds may indicate impending pulmonary edema. Early recognition of

After 8 hours of nursing intervention s, the patient was able to use identified techniques to enhance activity intolerance.

Collaborative: Obtain diagnostic studies including complete blood count, hemoglobin and hematocrit, urine, vaginal ang cervical cultures as ordered.

possible adverse effects allows for prompt intervention. Monitor of uterine contractions provides evidence of effective therapy. Urine, vaginal, and cervical cultures help to rule out infection as a causative factor for preterm labor.

Ectopic Pregnancy

Assessment

Nursing Diagnosis
yAcute pain related to distention or rupture of fallopian tube.

Planning

Nursing Intervention
Independent: yMonitor maternal vital signs. yMonitor for presence and amount of vaginal bleeding. yMonitor for increase and pain and abdominal distention and rigidity. yMonitor complete blood count (CBC). yProvide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises. Provide diversional activities. yProvide Diversional activities. Collaborative:

Rationale

Evaluation

Subjective: Masakit ang tiyan ko (My tummy hurts) as verbalized by patient. Objective: yFacial mask of pain. yGuarding behavior. yV/S taken as follows: T: 36.4 P: 85 R: 22 Bp: 110/90

yAfter 8 hours of nursing interventions , the patient will be relieved or controlled.

yTo determine presence of hypotension and tachycardia caused by rupture or hemorrhage. yTo further assess the present situation indicating hemorrhage. yIncreased pain and abdominal distention indicates rupture and possible intraabdominal hemorrhage. yTo determine the amount of blood loss. yPromotes relaxation and may enhance patients coping abilities by refocusing attention. yDiversional activities aids in

yAfter 8 hours of nursing intervention s, the patient was relieved or controlled.

yAdminister analgesics as indicated.

refocusing attention and enhancing coping with limitations. yTo maintain acceptable level of pain.

Pregnancy Induced Hypertension (PIH; Preeclampsia and Eclampsia)

Assessment Nursing Diagnosis
Decreased cardiac output related to decreased venous return.

Planning

Nursing Intervention
Independent: yMonitor blood pressure of the patient. Measure in both arms or thighs three times, 3-5 minutes apart while patient is at rest, then sitting, then standing for initial evaluation. yObserve skin color, moisture, temperature and capillary refill time. yNote dependent or general edema. yProvide calm, restful surroundings, minimize environmental activity or noise. yMaintain activity restrictions.

Rationale

Evaluation

Subjective: Napansin ko na bigla na lang bumigat ang timbang ko (I

noticed that I gained a lot of weight) as

verbalized by the patient. Objective: yVariations in blood pressure. yEdema yV/S taken as follows: T: 37.1 P: 78 R: 20 BP: 140/90

yAfter 8 hours of nursing interventions, the patient will participate in activities that reduce blood pressure or cardiac work load.

yComparison of pressures provides a more complete picture of vascular involvement or scope of the problem. yPresence of pallor, cool, moist skin and delayed capillary refill time may be due to peripheral vasoconstriction yMay indicate heart failure, renal or vascular impairment. yHelp reduce sympathetic stimulation, promotes relaxation.

yAfter 8 hours of nursing interventions, the patient was able to participate in activities that reduce blood pressure or cardiac work load.

yInstruct in relaxation techniques, and guided imagery. Collaborative: yImplement dietary sodium, fat, and cholesterol restrictions as indicated.

yReduces physical stress and tension that affect blood pressure and course of hypertension. yCan reduce stressful stimuli, produce calming effect, thereby reduce blood pressure. yThese restrictions can help manage fluid retention and with associated hypertensive response, which decrease cardiac workload.

Placenta Previa
Assessment Nursing Diagnosis
Impaired fetal gas exchange related to altered blood flow and decreased surface area of gas exchange at site of placental detachment.

Planning

Nursing Intervention
Independent: yAssess vital signs (pulse, respirations, and blood pressure every 15 minutes). yMaintain bed rest or chair rest when indicated. Provide frequent rest periods and uninterrupted night time sleep. yMonitor amount and type of bleeding. yPosition mother on her left side. yRestrict vaginal examination. yMonitor uterine contractions and fetal heart rate by external monitor. yMaintain positive

Rationale

Evaluation

Subjective: Bigla na lang akong dinugo (Im bleeding) as verbalized by the patient. Objective: yChanges in fetal heart rate or fetal activity. yRelease of meconium. yV/S taken as follows: T: 36.9 P: 96 R: 22 Bp: 100/80

After 8 hours of nursing interventions, the patient will verbalize understanding of causative factors and appropriate interventions.

y.Provides baseline data on maternal blood loss. ySystemic rest is mandatory and important throughout all phases of disease to reduce fatigue, and improve strength. yProvide objective evidence of bleeding. yTo promote placental perfusion. yPrevents tearing of placenta if placenta previa is the cause of bleeding. yAssess whether labor is present

yAfter 8 hours of nursing interventions, the patient was able to verbalize understanding of causative factors and appropriate interventions.

attitude toward about fetal outcome.

and fetal status and external system avoids cervical trauma. ySupports mother and child bonding. yProvides adequate fetal oxygenation despite of lowered maternal circulating volume.

Collaborative: yAdminister oxygen as indicated.

Gouty Arthritis
Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

http://nursingcrib.com/category/nursing-care-plan/

Leptospirosis
Assessment Nursing Diagnosis
jAcute pain related to bacterial infections in the body.

Planning

Nursing Intervention
Independent: jAssess reports of pain, including location and intensity (scale of 0-10). jObserve nonverbal cues. jExplore alternative pain relief measure like relaxation technique, breathing techniques and guided imagery. jCarefully position affected part. jApply local massage gently to affected areas. jEncourage range of motion

Rationale

Evaluation

SUBJECTIVE: Napakasakit ng ulo at buong katawan (I had

a horrible headache and body aches) as

verbalized by the patient. OBJECTIVE: jFacial grimacing jIrritability jGuarding of the affected areas. jV/S taken as follows: T: 37.3 P: 89 R: 23 BP: 110/70

jAfter 8 hours of nursing interventions, the patient will demonstrate use of relaxation skills, other methods to promote comfort and to relieve pain.

jTo provide base line information. jPain is unique to each patient. One may encounter varying descriptions because of individualized perceptions. Non verbal cues may aid in evaluation of pain and effectiveness of therapy. jCognitive behavioral interventions may reduce reliance on pharmacological therapy and enhance patient s sense of

jAfter 8 hours of nursing interventions, the patient was able to demonstrate use of relaxation skills, other methods to promote comfort and to relieve pain.

exercises. jMaintain adequate fluid intake. Collaborative: jAdminister medication as indicated like analgesics and antibiotics.

control. jReduces discomfort, and risk for injury. jHelp reduce muscle tension. jPrevents joint stiffness and possible contracture formation. jDehydration increases sickling and corresponding pain. jAnalgesics reduces pain and promotes rest and comfort, while antibiotics inhibits further bacterial infection.

Hypertension
Assessment Nursing Diagnosis
jRisk for prone behavior related to lack of knowledge about the disease

Planning

Nursing Intervention
INDEPENDENT: jDefine and state the limits of desired BP. Explain hypertension and its effect on the heart, blood vessels, kidney, and brain. jAssist the patient in identifying modifiable risk factors like diet high in sodium, saturated fats and cholesterol. jReinforce the importance of adhering to treatment regimen and keeping

Rationale

Evaluation

SUBJECTIVE: Bakit kaya madalas ako mahilo? (Why do

I always feel dizzy?)

as verbalized by the patient. OBJECTIVE: jRequest for information. jAgitated behavior jInaccurate follow through of instructions. jV/S taken as follows: T: 37.2 P: 84 R: 18 BP: 180/110

jAfter 8 hours of nursing interventions, the patient will verbalize understanding of the disease process and treatment regimen.

jProvides basis for understanding elevations of BP, and clarifies misconceptions and also understanding that high BP can exist without symptom or even when feeling well. jThese risk factors have been shown to contribute to hypertension. jLack of cooperation is common reason for failure of antihypertensive therapy. jDecreases peripheral venous pooling

jAfter 8 hours of nursing interventions, the patient was able to verbalize understanding of the disease process and treatment regimen.

follow up appointments. jSuggest frequent position changes, leg exercises when lying down. jHelp patient identify sources of sodium intake. jEncourage patient to decrease or eliminate caffeine like in tea, coffee, cola and chocolates. jStress importance of accomplishing daily rest periods. COLLABORATIVE: jProvide information regarding community resources, and support patients in making lifestyle changes.

that may be potentiated by vasodilators and prolonged sitting or standing. jTwo years on moderate low salt diet may be sufficient to control mild hypertension. jCaffeine is a cardiac stimulant and may adversely affect cardiac function. jAlternating rest and activity increases tolerance to activity progression. jCommunity resources like health centers programs and check ups are helpful in controlling hypertension.

Amoebiasis/Amebiasis (Amoebic Dysentery)

Assessment Nursing Diagnosis
SUBJECTIVE: Sumasakit and tiyan ko at madalas akong dumumi (I have
been having severe diarrhea and abdominal pain) as

Planning

Nursing Intervention
INDEPENDENT: jMonitor intake and output, character, and amount of stools; estimate insensible fluid losses. Measure urine specific gravity and observe for oliguria. jAssess vital signs (BP, pulse, temperature). jObserve for excessively dry skin and mucous membranes, decreased skin turgor, slowed capillary refill. jWeigh daily. jMaintain oral restrictions, bed rest

Rationale
jProvides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement. jHypotension (including postural), tachycardia, fever can indicate response to or effect of fluid loss. jIndicates excessive fluid loss or resultant of dehydration. jIndicator of overall fluid and nutritional status. jColon is placed

Evaluation

SUBJECTIVE: Sumasakit and tiyan ko at madalas akong dumumi (I have

been having severe diarrhea and abdominal pain) as

verbalized by the patient. OBJECTIVE: jRestlessness jIrritability jFacial grimace jDry skin jV/S taken as follows: T: 37.4 P: 79 R: 19 BP: 110/70

verbalized by the patient. OBJECTIVE: jRestlessness jIrritability jFacial grimace jDry skin jV/S taken as follows: T: 37.4 P: 79 R: 19 BP: 110/70

After 8 hours of nursing interventions, the patient will maintain adequate fluid volume as evidenced by good skin turgor and balance intake and output.

After 8 hours of nursing interventions, the patient was able to maintain adequate fluid volume as evidenced by good skin turgor and balance intake and output.

and avoidance of exertion. jObserve for overt bleeding and test stool daily for occult blood. jNote generalized muscle weakness or cardiac dysrhythmias. COLLABORATIVE: jAdminister parenteral fluids as indicated. jAdminister medications as indicated: Antidiarrheal and antibiotics.

at rest for healing and to decrease intestinal fluid losses. jInadequate diet and decreased absorption may lead to vitamin K deficiency and defects in coagulation, potentiating risk for hemorrhage. jExcessive intestinal loss may lead to electrolyte imbalance. jMaintenance of bowel rest requires alternative fluid replacement to correct losses. jTo reduces fluid losses in the intestine and to prevent further spread of the bacteria.

Colon Cancer (Colorectal Cancer)

Assessment Nursing Diagnosis
jFatigue related to altered body chemistry, side effects of pain and other medications, chemotherapy

Planning

Nursing Intervention
INDEPENDENT: jHave patient rate fatigue, using a numeric scale, if possible, the time of day when it is most severe. jPlan care to allow rest periods. Schedule activities for periods when patient has most energy. jAssist patient with self-care needs. Keep bed in low position and assist with ambulation. jEncourage patient to do whatever possible and increase activity level as tolerated. jPerform pain

Rationale

Evaluation

SUBJECTIVE: Nanghihina ako, pakiramdam ko lagi akong pagod. (I feel

very tired and weak)

as verbalized by the patient. OBJECTIVE: jDisinterest in the surrounding. jLethargy jV/S taken as follows: T: 37.3 P: 90 R: 22 BP: 120/80

jAfter 8 hours of nursing interventions, the patient will report improved sense of energy.

jHelp in developing a plan for managing fatigue. jFrequent rest periods or naps are needed to restore or conserve energy. Planning will allow patient to be active during times when energy level is higher, which may restore feeling of well being and a sense of control. jWeakness may make activities of daily living and ambulation difficult, further

jAfter 8 hours of nursing interventions, the patient was able to report improved sense of energy.

assessment and provide pain management as prescribed. jEncourage nutritional intake. COLLABORATIVE: jRefer for physical therapy.

assistance is needed. jEnhances strength and enables patient to become more active without undue fatigue. jPoorly managed cancer pain can contribute to fatigue. jAdequate intake of nutrients is necessary to meet energy needs and build energy reserves for activity. jProgrammed daily exercises and activities help patient maintain or increase strength and muscle tone which enhances sense of well being.

Postpartum Hemorrhage
Assessment Nursing Diagnosis
Risk for ineffective tissue perfusion related to hemorrhage.

Planning

Nursing Intervention
Independent: yMonitor amount of bleeding by weighing all pads. yFrequently monitor vital signs. yMassage the uterus. yPlace the mother in Trendelenberg position. yProvide comfort measure like back rubs, deep breathing. Instruct in relaxation or visualization exercises. Provide diversional activities. Collaborative: yAdminister oxygen as indicated.

Rationale

Evaluation

Subjective: Halos ilang linggo na ako nakapanganak pero malakas pa rin ang pagdurugo ko (Im still bleeding
heavily after weeks of giving birth) as

yAfter 8 hours of nursing interventions , the patient will demonstrate adequate perfusion and stable vital signs.

verbalized by patient. Objective: yRestlessness yConfusion. yIrritability. yV/S taken as follows: T: 36.8 P: 105 R: 24 Bp: 100/70

yTo measure the amount of blood loss. yEarly recognition of possible adverse effects allows for prompt intervention. yTo help expel clots of blood and it is also used to check the tone of the uterus and ensure that it is clamping down to prevent excessive bleeding. yEncourages venous return to facilitate circulation, and prevent further bleeding.

yAfter 8 hours of nursing interventions, the patient was able to demonstrate adequate perfusion and stable vital signs.

yAdminister medication as indicated (e.g Pitocin, Methergin)

yPromotes relaxation and may enhance patients coping abilities by refocusing attention. yTo supply adequate oxygen to the fetus and mother and prevents further complication. yTo promote contraction and prevents further bleeding.

Neonatal Sepsis (Sepsis Neonatorum)

Assessment Nursing Diagnosis
Risk for infection related to compromised immune system.

Planning

Nursing Intervention
INDEPENDENT: jProvide isolation and monitor visitors as indicated. jWash hands before or after each care activity, even gloves are used. jLimit use of invasive devices or procedure as possible. jInspect wounds or site of invasive devices, paying particular attention to parenteral lines. jMaintain sterile technique when changing

Rationale

Evaluation

SUBJECTIVE: Walang gana dumede ang anak ko, parang mainit sya at hindi nagkikilos. ( It s
difficult to feed my baby, she feels warm to touch and not very active ) as

jAfter 8 hours of nursing interventions, the patient will achieve timely healing and free from further infection.

verbalized by the mother. OBJECTIVE: jIncreased body temperature. jFlushed skin. jIncreased respiratory rate. jV/S taken as follows: T: 37.8C P: 130 R: 45

jBody substance isolation (BSI) should be used for all infectious patients. Reverse isolation/restriction of visitors may be needed to protect the immunosuppressed patient. jReduces risk of cross contamination because gloves may have noticeable defects, get torn or damaged during use. jPrevents spread of infection via airborne droplets. jMay provide clue to portal entry, type of primary infecting

jAfter 8 hours of nursing interventions, the patient was able to achieve timely healing and free from further infection.

dressings, suctioning or providing site care. jProvide tepid sponge bath and avoid use of alcohol. jObserve for chills and profuse diaphoresis. jMonitor for signs of deterioration of condition or failure to improve in therapy. COLLABORATIVE: jObtain specimens of urine, blood, sputum, wound as indicated for gram stain, and sensitivity. jAdminister antibiotics as prescribed.

organisms, as well as early identification secondary infection. jPrevents introduction of bacteria, reducing risk of nosocomial infection. jUsed to reduce fever. jChills often precede temperature spikes in presence of generalized infection. jMay reflect inappropriate antibiotic therapy or overgrowth of secondary infections. jIdentification of portal entry and organism causing the septicemia is crucial in effective treatment. jTo prevent further spread of infection.

Diabetes Mellitus Type 1

Assessment Nursing Diagnosis
yFluid volume deficient related to osmotic diuresis from hyperglycemia

Planning

Nursing Intervention
Independent: yMonitor orthostatic blood pressure changes. yMonitor respiratory pattern like Kussmauls respirations and acetone breath. yMonitor temperature, skin color and moisture. yAssess peripheral pulses, capillary refill, skin turgor, and mucous membrane. yMonitor input and output. Note urine specific gravity. yWeigh daily. yMaintain fluid intake at least 2500 ml / day

Rationale

Evaluation

Subjective: Pakiramdam ko lagi akong nanghihina saka na uuhaw (I feel

weak and Im always thirsty) as

verbalized by the patient. Objective: yDry skin and mucous membrane. yPoor skin turgor. ySudden weight loss. yV/S taken as follows: T:37.1 P:85 R:20 BP: 110/80

yAfter 8 hours of nursing interventions, the patient will demonstrate adequate hydration.

yHypovolemia may be manifested by hypotension and tachycardia. yLungs remove carbonic acid through respirations, producing a compensatory respiratory alkalosis for ketoacidosis. yFever, chills, and diaphoresis are common with infectious process; fever with flushed, dry skin may reflect dehydration. yIndicators of level of dehydration, adequacy of circulating volume.

yAfter 8 hours of nursing intervention s, the patient was able to demonstrate adequate hydration evidenced by stable vital signs, palpable peri pheral pulses, good skin turgor and capillary refill.

within cardiac tolerance with oral intake is resumed. yPromote comfortable environment. Cover patient with light sheets. Collaborative: yAdminister fluids as indicated.

yProvides ongoing estimate of volume replacement needs, kidney function, and effectiveness of therapy. yProvides the best assessment of current fluid status and adequacy of fluid replacement. yMaintains hydration and circulating volume. yAvoids overheating, which could promote further fluid loss. yType and amount of fluid depend on the degree of deficit and individual patient response.

Diabetes Mellitus Type 2

Assessment Nursing Diagnosis
yRisk for infection related to high glucose levels, decreased leukocyte function.

Planning

Nursing Intervention
Independent: yObserve for signs of infection and inflammation. yPromote good handwashing by nurse and patient. yMaintain aseptic technique for IV insertion procedure, administration of medications, and providing maintenance and site care. Rotate IV sites as indicated. yProvide catheter or perineal care. Teach the female patient to clean from front to back after elimination. yProvide conscientious skin care, gently massage bony areas. Keep the

Rationale

Evaluation

Subjective: Hindi gumagaling ang sugat ko

(My wounds are not healing) as

verbalized by the patient. Objective: yFlushed appearance. yWound drainage. yV/S taken as follows: T:37.4 P:87 R:19 BP: 120/90

yAfter 8 hours of nursing interventions, the patient will identify interventions to prevent or reduce risk of infection.

yPatient may be admitted with infection, which could have precipitated the ketoacidotic state, or may develop a nosocomial infection. yReduces the risk of crosscontamination yHigh glucose in the blood creates an excellent medium for bacterial growth. yMinimizes the risk for infection. yPeripheral circulation may be impaired, placing patient at increased risk for skin irritation or

yAfter 8 hours of nursing intervention s, the patient was able to identify intervention s to prevent or reduce risk of infection.

skin dry, linens dry and wrinkle free. yPlace in semi fowlers position. yEncourage adequate dietary and fluid intake of 3000 ml per day. Collaborative: yObtain specimen for culture and sensitivities as indicated.

breakdown and infection. yFacilitates lung expansion and reduces risk of aspiration. yDecrease susceptibility to infection. yIdentifies organisms so that most appropriate drug therapy can be instituted.

Kyphosis
Assessment Nursing Diagnosis
jImpaired physical mobility related to neuromascular impairment.

Planning

Nursing Intervention
INDEPENDENT: jContinually assess motor function by requesting patient to perform certain actions like shrugging shoulders, spreading fingers. jAssist with full range of motion exercises in all extremities and joints using slow, smooth movements. jPosition arms at 90-degree angle at regular intervals. jElevate lower extremities at intervals when in chair or raise foot or bed when permitted in individual

Rationale
jEvaluates status of individual situation, affecting type and choice of interventions. jEnhances circulation, restores muscle tone and joint mobility. jPrevents frozen shoulder contractures. jLoss of vascular tone and muscle action results in pooling of blood and venous stasis in the lower abdomen and lower extremities, with increased risk of hypotension and thrombus formation.

Evaluation

SUBJECTIVE: Nanghihina ako, pakiramdam ko hindi ko kayang gumalaw (I feel

weak, I can t move)

as verbalized by the patient. OBJECTIVE: jParalysis. jMuscle atrophy. jV/S taken as follows: T: 37.1 P: 89 R: 20 BP: 110/90

jAfter 8 hours of nursing interventions, the patient will demonstrate techniques or behaviors that enable resumption of activity.

jAfter 8 hours of nursing interventions, the patient was able to demonstrate techniques or behaviors that enable resumption of activity.

situation. jPlan activities to provide uninterrupted rest periods. Encourage involvement within individual tolerance or ability. jEncourage use of relaxation techniques. jInspect skin daily. Observe for pressure areas and provide meticulous care. COLLABORATIVE: jConsult with physical therapist.

jPrevents fatigue, allowing opportunity for maximal efforts or participation by the patient. jReduces muscle tension, may limit pain of muscle spasm. jAltered circulation, loss of sensation, and paralysis potentiate pressure sore formation. jHelpful in planning and implementing individualized exercise program and identifying assistive devices to maintain function, enhance mobility and independence.

Assessment

Nursing Diagnosis

Planning

Nursing Intervention

Rationale

Evaluation

http://nursingcrib.com/category/nursing-care-plan/